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SYMPTO^ilS 

AND    THEIR    INTEHPRETATION 


TO    THE 
MEMORY    OP    MY    TEACHER 

Professor  W.  R.  SANDERS. 


SYMPTOMS  AND  THEIR 
INTERPRETATION 


BY 


James  Mackenzie,  M.D.,LL.D.  [Aber.-i-^Edin.} 

Ledurer  on  Cardiac  Research.  London  Hospital ;   Physician  to  the  Mount  Vernon  Hospital ; 
Consulting  Physician  to  theVidoria  Hospital.  Burnley 


[third  edition} 


NEW  YORK 

PAUL  B.  HOEBER 

I9I8 


Digitized  by  the  Internet  Archive 

in  2010  with  funding  from 

Open  Knowledge  Commons 


\':D\'^ 


http://www.archive.org/details/symptomstheirintOOmack 


PREFACE 
TO   THE  THIRD  EDITION. 

TN  this,  the  third  edition  of  Symptoms  and 
-"^  their  Interpretation,  in  addition  to  a  number 
of  emendations  in  the  text,  I  have  added 
two  appendices.  One  of  them,  a  summary  of 
Mr.  Ligat's  investigations,  is  intended  to  demon- 
strate what  a  great  field  of  research  Hes  ready  to 
the  hand  of  the  surgeon,  and  what  an  impetus 
could  be  given  to  medical  knowledge  if  the  surgeon 
would  use  his  opportunities. 

I  am  often  asked  for  suggestions  by  willing 
workers  as  to  what  field  of  medicine  thej^  should 
investigate.  I  give  in  the  second  appendix  some 
suggestions,  which  are  the  outcome  of  my  experience, 
and  which  some  may  find  of  use. 

J.   M. 


PREFACE 

TO    THE    SECOND    EDITION. 


THE  exhaustion  of  the  first  edition  of  this  work 
and  its  translation  into  other  languages  has 
shown  an  appreciation  which  I  did  not  anticipate. 
It  has  been  gratifying  to  find  so  much  interest  evoked 
by  the  method  of  examination  described  in  this  book. 
Numerous  members  of  the  profession  have  testified  to 
me  the  real  help  they  have  obtained  in  examining 
patients  on  the  lines  here  laid  down. 

Several  writers  have  criticised  the  view  of 
visceral  pain  set  forth  in  this  book,  but  it  is  evident 
that  some  of  them  have  not  grasped  my  meaning, 
nor  sought  in  individual  instances  for  the  pheno- 
mena which  are  necessary  for  the  determination  of 
the  question.  Some  physiologists  have  imagined  that 
they  have  demonstrated  the  sensitivity  of  the  viscera, 
when  evident  distress  has  been  caused  in  an  animal 
by  injury  to  a  viscus.  In  making  such  a  claim,  they 
only  prove  that  with  an  adequate  stimulus  suffering 
may  be  caused,  but,  of  necessity,  they  cannot  from  an 
animal  acquire  the  knowledge  of  the  plienomena 
which  determine  the  mechanism  by  which  the  animal 
became  conscious  of  its  suffering,  for  such  phenomena, 
as  the  spread  of  pain  and  hyperalgesia,  are  incapable 
of  recognition  in  the  dumb   animal. 


viii.  Preface. 

Other  adverse  critics  who  have  studied  the  sub- 
ject chnically  have  practically  ignored  the  essential 
phenomena  associated  with  visceral  pain.  In  many 
cases  it  is  not  possible  to  prove  or  disprove  this  view 
in  the  absence  of  these  confirmatory  evidences,  but 
by  the  careful  and  continuous  observation  of  cases 
with  visceral  pain,  unquestionable  e\'idence  will  be 
forthcoming. 

In  preparing  this  edition,  I  gratefully  acknow- 
ledge the  help  and  criticism  given  me  by  Professor 

David  Waterston. 

J.   M. 

133,  Harley  Street, 

London,  W. 


PREFACE. 

IN  the  following  pages  I  draw  attention  to  the 
valuable  aid  to  diagnosis  afforded  by  the 
careful  study  of  pain,  and  the  nervous  phe- 
nomena which  accompany  it.  The  recognition  of 
these  nervous  phenomena  provides  the  means  for 
ascertaining  how  many  of  the  symptoms  of  disease 
are  produced.  Although  much  has  been  done  to  elicit 
the  more  obscure  symptoms  that  arise  from  dis- 
ordered functions  of  diseased  viscera,  comparatively 
little  attention  has  been  paid  to  the  more  obvious 
symptoms.  While  I  am  far  from  decrying  the 
importance  of  the  advances  that  have  been  made 
in  what  may  be  called  the  laboratory  methods  of 
clinical  diagnosis,  yet  the  practical  value  of  these 
methods  to  the  general  practitioner  is  very  small 
compared  to  the  information  to  be  gained  by  the 
recognition  of  the  symptoms  arising  from  reflex 
stimulation  of  the  nervous  sj^stem.  It  is  only  in  a 
small  proportion  of  the  cases  which  the  general  prac- 
titioner sees  that  the  more  intricate  methods  of 
examination  are  of  use,  or  are  available,  while  in  the 
great  majority  of  cases  the  reflex  symptoms  lie  ready 
to  his  liand,  and  it  is  on  these  alone  he  has  often  to 
rely  for  diagnosis  and  treatment.  It  must  be  borne  in 
mind  that  the  general  practitioner  sees  a  vast 
number  of  cases  wliicli  are  never  met  witli  in  hospital 


X.  Preface. 

wards.  Text-books  are  too  often  written  from 
the  standpoint  of  an  experience  gained  in  the 
hospital  or  consulting  room  ;  their  authors  necessarily 
see  the  more  advanced  cases,  and  do  not  realise 
sufficiently  the  class  of  patient  which  the  general 
practitioner  has  daily  to  treat.  The  earty  stages  of 
disease  are,  therefore,  not  fully  appreciated,  and 
can  never  be  fully  appreciated  till  the  general 
practitioner  takes  his  position  as  an  investigator. 
I  hope  to  show  in  the  following  pages  that  there 
is  not  onl}^  a  wide  field  open  to  him  for  exploration 
that  can  be  accomplished  b}^  simple  practical 
methods,  but  that  the  results  that  await  his 
investigation  are  equal  in  importance  to  those 
acquired  by  the  more  recondite  methods  used  in 
well-equipped  hospital  wards  or  laboratories.  No 
one  has  such  opportunities  for  the  observance  of 
the  earty  symptoms  in  disease,  and  no  one  can 
so  readily  follow  the  changes  that  occur  in  the 
advance  of  disease.  The  nature  of  the  early  symp- 
toms and  the  prognosis  of  disease  are  amongst  the 
least  understood  matters  in  medicine. 

The  views  put  forth  here  are  the  outcome  of 
an  inquiry  that  has  extended  over  twent}^  years.  I 
have  endeavoured  to  utilise  the  opportunities  of  a 
general  practitioner  to  study  the  earliest  symptoms 
of  disease  and  the  bearing  of  the  disease  upon  the 
patient's  future  life  in  times  of  suffering  and  of 
stress,  as  when  affected  by  other  illnesses,  by 
pregnancy,  or  by  hard  bodily  labour.  A  great  deal  of 
preparatory  work  had  to  be  done  to  find  out  what 
S}'mptoms  were  serviceable,  and  to  understand  the 
meaning  and  mechanism  of  these  symptoms.  In 
this  work  symptoms  that  had  been  overlooked  or 


Preface.  xi. 

ignored  have  received  special  attention,  and  the 
study  of  some  of  them  has  given  a  clearer  conception 
of  the  nature  of  many  phenomena. 

In  dealing  with  the  reflex  phenomena  of  disease, 
as  a  basis  on  which  to  found  a  rational  principle  of 
diagnosis,  I  have  limited  niA^self  chiefly  to  explaining 
the  nature  of  these  reflex  phenomena,  passing  over 
more  cursorily  the  symptoms  that  arise  from  changes 
in  function  or  in  the  structure  of  organs  as  revealed 
by  physical  signs,  since  these  are  dealt  with  more  or 
less  fully  in  every  book  on  diagnosis.  I  mention 
this  lest  it  might  be  inferred  from  the  scant  reference 
to  these  symptoms  that  I  held  them  of  small 
importance. 

After  setting  forth  the  principles  on  which  diag- 
nosis should  be  based,  I  give  illustrative  exam.ples 
in  the  application  of  this  doctrine  to  diseases  of 
certain  viscera.  The  description  of  the  symptoms 
present  in  the  affection  of  any  organ  does  not 
profess  to  be  complete — it  would  have  led  me 
too  far  afield  to  have  attempted  a  complete 
description — and  an  outline  only  is  given  of 
the  manner  in  which  the  symptoms  arise,  and  the 
nature  of  these  symptoms.  I  have  been  able  to  work 
out  the  symptoms  in  detail  in  only  a  few  organs,  as 
the  heart  and  stomach,  and  even  all  the  symptoms 
in  these  are  not  fully  comprehended.  The  symptoms 
in  heart  affections  afford  good  opportunities  for 
detecting  the  real  nature  of  the  reflex  phenoniena,  on 
account  of  the  peculiar  fiekl  in  whicli  the  symptoms 
appear,  and  the  ease  with  which  the  heart's  action 
can  be  studied.  As  the  production  of  the  reflex 
])henomena  are  fundamentally  the  same  in  all  viscera, 
1    have    frequently    used    tlie    symptoms    in    heart 


xii.  Preface. 

affections  to  illustrate  the  principles  underlying  the 
S3'mptoms  in  disease  of  other  organs. 

It  is  hoped  that  not  only  the  general  practi- 
tioner, but  also  the  surgeon  and  physician,  will  find 
the  methods  here  described  of  use.  Our  present 
diagnostic  powers,  in  regard  to  abdominal  affections 
for  instance,  stand  sadly  in  need  of  strengthening. 
It  is  a  matter  of  common  experience  to  find  skilled 
surgeons,  who  are  daily  operating  on  abdominal 
organs,  giving  widely  divergent  opinions  as  to  the 
nature  of  the  complaint  in  some  single  individual. 
In  a  measure  the  ease  and  supposed  safety  with 
which  an  abdominal  exploration  can  be  performed 
has  thrown  back  the  need  of  a  careful  and  pains- 
taking examination  into  the  nature  of  the  symptoms, 
so  that  much  confusion  exists  in  regard  to  the  nature 
and  origin  of  many  easily  recognised  phenomena. 
This  confusion  is,  in  a  great  measure,  due  to  the  fact 
that  the  reflex  phenomena  of  visceral  disease  have 
not  been  sufficiently  appreciated.  The  description 
given  in  this  book  is  not  a  solution,  but  an  attempt 
to  bring  forward  the  means  of  arriving  at  a  solution. 

It  may  be  said  that  I  have  not  sufficiently 
recognised  the  work  done  hj  other  observers  in  this 
field.  While  I  have  in  the  main  followed  my  own 
line  of  observation,  I  acknowledge  the  many  valuable 
suggestions  I  have  obtained  from  the  writings  of 
Hilton,  Ross,  Head,  Maylard,  Moynihan,  Keaj^ 
Lennander,  Ramstrom,  and  others.  I  have  also  to 
express  my  indebtedness  for  advice  and  help  from 
my  friends  Sir  Clifford  Allbutt,  Professor  Cushny, 

Dr.  Purves  Stewart,  and  Dr.  John  Muir. 

J.  M. 

■  133,  Harley  Street, 

London,  W. 


(     xiii.     ) 


CONTENTS. 


Chapter  I.     Pages  1 — 16. 

Introduction. 

1.  Medicine  a  science.  2.  Accuracy  of  observation. 
3.  Method  of  observation.  4.  The  vahie  of  a  hypothesis.  5.  The 
parsimony  of  hypotheses.     6.  Nomenclature. 

Chapter  II.     Pages  17 — 23. 

Classification  of  the  Symptoms  of   Disease. 

7.  Reflex  symptoms.  8.  Purpose  of  reflex  symptoms. 
9.  Functional  symptoms.  10.  Structural  symptoms  revealed  by 
physical  signs.     11.  The  relative  importance  of  symptoms. 

Chapter  III.     Pages  24—31. 

Pain. 

12.     Definition  of  pain.         13.  Constitution  of  the  nervous 

system.       14.  The    sensitiveness   of   tissues    to    painful    stimuli. 

15.  Mechanism  by  which  pain  is  produced.       16.  Radiation  of 

pain. 

Chapter  IV.     Pages  32 — 53. 

Visceral  Pain. 

17.  The  function  of  afferent  sympathetic  nerve  fibres. 
18.  Insensitiveness  of  the  viscera  to  stimulation.  19.  Sensitive 
tissues  of  the  external  body  wall.  20.  Testicular  pain. 
21.  Artificial  production  of  visceral  pain.  22.  Relationship  of 
the  site  of  pain  to  the  site  of  the  lesion,  23.  Mechanism  by  which 
paui  is  produced  in  visceral  disease.  24.  Referred  pain. 
25.  Radiation  of  visceral  pain.  26.  Pain  the  only  sensory  reflex 
in  visceral  disease.     27.  Lennander's  observations. 


xiv.  Contents. 

Chapter  V.     Pages  54 — 62. 
Visceral  Pain  {continued). 

28.  Objections  to  the  referred  nature  of  visceral  pain. 

Chapter  VI.     Pages  63—70. 
Increased  sensibility  of  the  external  body  wall. 

29.  Hyperalgesia.  30.  Cutaneous  hyperalgesia.  31.  Mus- 
cular hyperalgesia.  32.  Hyperalgesia  of  other  structures. 
33.  Effect  of  exercise  on  hyperalgesic  muscles.  34.  The  areas  of 
cutaneous  hyperalgesia.  35.  The  areas  of  muscular  hyperalgesia. 
36.  Tender  vertebrae. 

Chapter  VII.     Pages  71 — 77. 

The    Viscero-motor  Reflex. 

37.  Definition.  38.  Effects  of  stimulation  of  motor  nerves 
on  limb  muscles  and  on  flat  abdominal  muscles.  39.  Character 
of  the  viscero-motor  contraction.  40.  Conditions  causing  the 
viscero-motor  reflex.  41.  Experimental  production  of  the 
viscero-motor  reflex. 

Chapter  VIII.     Pages  78—83. 

Organic  Reflexes. 

42.  Vomiting.  43.  Dyspnoea.  44.  Secretory  reflexes. 

45.  Cardiac  reflexes.     46.  Vaso-motor  and  pilo-motor  reflexes. 


Chapter  IX.     Pages  84—98. 

Laws  determining  the  nature  of  the  Reflex  Symptoms. 

47.  Mechanism    of   the   production    of    "  direct    pain "    and 

"  referred     pain."       48.  The     viscero-motor     reflex.       49.  The 

organic     reflexes.       50.  Irritable     foci     in     the     spinal     cord. 

51.  Exaggerated    reflexes    due    to    irritable    foci    in    the    cord. 

52.  Relation  of  visceral  lesion  to  site  of  reflex. 


Contents.  xv. 

Chapter  X.     Pages  99—108. 

Preliminary  Examination  of  the  Patient. 

53.  The  patient's  appearance.  54.  The  patient's  sensations. 
55.  Facial  aspect.  56.  The  general  condition.  57.  A  review 
of  all  the  organs. 


Chapter  XI.     Pages  109—114. 

Symptoms    of     Affections    in    the    region    of     Distribution    of 
Cerebrospinal   Nerves. 

58.  Headache.     59.  Sensory  and  motor  symptoms.     60.  Dif- 
ferential diagnosis. 


Chapter  XII.     Pages  115—130. 

Affections  of  the   Digestive  Organs. 

61.  The  nerve  supply  of  the  digestive  tract.  62.  Distri- 
bution of  sensory  symptoms  in  affections  of  the  digestive  tract. 
63.  Appetite.  64.  Hunger.  65.  Nausea.  66.  Mouth  and 
fauces.       67.  Tongue.       68.  Swallowing.       69.  (Esophagus. 


Chapter  XIII.     Pages  131—155. 

Affections  of  the    Digestive  Organs  {continued). 
The  Stomach. 

70.  The  nature  of  the  symptoms.  71.  Nerve  supply  of 
the  stomach.  72.  The  site  of  pain  in  affections  of  the  stomach. 
73.  The  character  of  the  pain  and  its  relation  to  the  ingestion  of 
food.  74.  Hyperalgesia.  75.  Superficial  reflexes.  76.  Viscero- 
motor reflexes.  77.  Vomiting.  78.  Pyrosis  and  heart-burn. 
79.  Air  suction.  80.  Functional  symptoms.  81.  Structural 
symptoms.  82.  The  diagnosis  of  stomach  affections.  83.  Pain 
in  gastric  ulcer. 


xvi.  Contents. 

Chapter  XIV.     Pages  156—166. 

The  Liver,   Gall-bladder,  and    Ducts. 

84.  Nerve  supply.  85.  Keflex  symptoms  iu  gall-stone 
disease.  86.  Gastric  symptoms  in  gall-stone  disease.  87.  The 
result  of  reflex  symptoms.  88.  Functional  symptoms  in  gall- 
stone disease.  89.  Structural  symptoms  in  gall-stone  disease. 
90.  Fever  in  gall-stone  disease.  91.  Nature  of  reflex  symptoms 
in  affections  of  the  liver.  92.  Functional  symptoms  in  affections 
of  the  liver.     93.  Structural  symptoms  in  affections  of  the  liver. 

Chapter  XV.     Pages  167—177. 

The  Great  and  Small  Intestine. 

94.  Difficulties  in  diagnosis.  95.  Pain.  96.  Appendicitis. 
97.  Affections  about  the  anus  and  perineum.  98.  Perineal  reflex. 
99.  Functional    symptoms.     100.  Structural    symptoms. 

Chapter  XVI.     Pages  178 — 192. 

Affections  of  the    Urinary  System. 

101.  Symptoms  of  affections  of  the  kidney.  102.  Symptoms 
of  affections  of  the  pelvis  of  the  kidney  and  ureter. 
103.  Symptoms  of  affections  of  the  bladder. 

Chapter  XVII.     Pages  193—197. 

Affections  of   Female  Pelvic  Organs. 
104.  The    uterus.        105.  The    ovaries.        106.  The    vagina. 

Chapter  XVIII.     Pages  198—203. 

Peritonitis  and  Peritoneal    Adhesions. 

107.  Insensitiveness  of  the  peritoneum.  108.  Symptoms 
in  peritonitis.  109.  Symptoms  in  peritoneal  adhesions  (parietal). 
110.     Symptoms  in  peritoneal  adhesions  (visceral). 


Contents.  xvii. 

Chapter  XIX.     Pages  204—218. 

Affections  of  the  Lungs  and  Pleura. 

111.  Nature  of  the  subjective  sensations.  112.  The  respira- 
tion. 113.  Reflex  symptoms.  114.  Functional  symptoms. 
115.  Structural  symptoms.  116.  Affections  of  the  pleura, 
117.  Nature  of  the  pain  in  pleurisy. 

Chapter  XX.     Pages  219—250. 

Affections  of  the  Circulatory  System. 

118.  Heart  failure.  119.  The  nature  of  the  symptoms  in 
heart  failure.  120.  Consciousness  of  the  heart's  action. 
121.  Breathlessness.  122.  Viscero-sensory  and  viscero-motor 
reflexes.  123.  The  viscero-sensory  reflexes  in  dilatation  of  the 
heart  and  liver.  124.  The  pain  of  angina  pectoris  is  a 
viscero-sensory  reflex.  125.  Evidences  of  the  viscero-motor 
reflex.  126.  Organic  reflexes.  127.  Summation  of  stimuli 
the  cause  of  angina  pectoris. 

Chapter  XXI.     Pages  251—268. 

Estimation  of  the    Value  of  Symptoms. 

128.  The  relation  of  the  symptoms  to  the  general  state. 
129.  Remote  effects  of  the  lesion.  130.  Relation  of  symptoms 
arising  from  different  causes.  131.  The  bearing  of  symptoms 
on  prognosis.     132.  The  bearing  of  symptoms  on  treatment. 

APPENDICES. 

Appendix  I.     Page  269. 
Mr.  Ligat  on  Hyperalgesia  in  Abdominal  Muscles. 

Appendix  II.     Page  273. 
Clinical  Investigation. 


(     xix. 


LIST    OF    ILLUSTRATIONS. 


PAGE 

Fig.    L   Diagram    of    the    origin    and    distribution    of    the    efferent 

autonomic  nervo  fibres  .....       27 

Fig.   2.  Shows      the      vertebrae      that      may      become      tender      in 

affections  of  the  heart,  stomach,  liver,  &c.  -        69 

Fig.   3.   Diagram    showing    the    mechanism    by    which    pain    and 

the  superficial  reflexes  are  produced  -  -     '    -        86 

Fig.  4.  Diagram  showing  the  mechanism  by  which  pain,  the 
viscero-sensory  reflexes,  the  viscero-motor  reflexes, 
and  the  organic  reflexes  are  produced  in  visceral 
disease  ....  ...       87 

Fig.  5.  Diagram  "of  a  primitive  vertebrate  -         -         -         -       94 

Fig.   C.  Shows    the    areas    of    i)ain    and    hyi)eralgesia    in    angina 

pectoris  ........       <jo 

Fig.   7.  Shows   the   area   of   eruption   in    a   case   of   herpes   zoster 

affecting  the  upjier  thoracic  nerves  ■         -         -       97 

Fig.   8.  Shows  the  areas  in  which  pain  is  folt   in  affections  of  the 

digestive  tube  -         •         -         -         -         -         -117 

l'"i(i.    9.   Shows    the    seat   oi   pain,    and    the    position    of    the   gastric 

ulcer  causing  the  pain         -  -  -  -  -  -].")(» 

Fig.    10.   Shows  the  seat  of  pain,   and   the  position  of  the  gastric 

ulcer  causing  the  pain  -         -         •         -         •      !r)2 

Fig.    11.   Shows  the  seat  of  pain,   and   tlin   position  of  the  gastric 

ulcer  causing  the  pain  ....  154 


XX.  List  of  Illustrations. 


PAGE. 

Fig.    12.  Shows    the    region    of    cutaneous    hyperalgesia    after    an 

attack  of  gall-stone  colic  -  -  -  -      158 

Fig.   13.  Shows    the    region    of    cutaneous    hyperalgesia    after    an 

attack  of  renal  colic  -  -  -  -  -  -     183 

Fig.    14.   Shows    the    region    of    cutaneous    hyperalgesia    after    an 

attack  of  renal  colic  -  -  -  -  -  -      187 

Fig.   15.   Shows   areas    of    pain    and    hyperalgesia    in    diaphragm- 
atic pleurisy       -  -  -  -  -  -  -  -     216 

Fig.    16.  Shows  areas  of  cutaneous  hyperalgesia    in    acute  dilata- 
tion of  the  heart  and  liver  .....     234 

Fig.   17.  Shows    the    area    of    cutaneous    hyperalgesia    after    the 

first  attack  of  angina  pectoris  ....     238 

Fig.   18.  Shows    the    areas    of    cutaneous    hyperalgesia    after    a 

number  of  attacks  of  angina  pectoris  -  -  -     238 

Fig    19.  Diagrammatic  illustration  of  the  hyperalgesia  points,  with 

typical  spread     -         -         -         -  -         -  -     271 


Chapter  I. 

INTRODUCTION. 

1.  Medicine  a  Science. 

2.  Accuracy  of  Observation. 

3.  Method  of   Observation. 

4.  The    Value  of  a   Hypothesis. 

5.  The  Parsimony  of   Hypotheses. 

6.  Nomenclature. 

1.  Medicine  a  Science.  —  Medicine  has  not 
attained  that  position  in  science  which  ought  of  right 
to  belong  to  lier.  Instead  of  leading  in  scientific 
development,  and  giving  guides  and  indications  to 
allied  branches,  she  is  too  often  content  languidly  to 
follow  in  their  wake,  or  to  pursue  some  erratic  course 
of  her  own.  The  observations  made  in  her  name  are 
frequently  made  more  to  support  some  vague  specu- 
lation or  far-fetched  theory  than  to  realise  the  actual 
condition  of  the  observed  phenomena.  The  sister 
sciences  in  place  of  seeking  for  assistance  from 
medicine  look  askance  at  the  wild  speculations  put 
forth  in  the  name  of  medical  science,  and  at  the  loose 
tliiiiking  and  play  of  the  imagination  which  many 
medical  writers  deem  legitimate  in  deahng  with  tlio 
phenomena  of  disease.  To  emancipate  medicine  from 
this  position  of  inferiority,  and  to  secure  for  it  that 

B 


2  Chapter  I. 

status  which  it  ought  to  possess,  an  effort  must  be 
made,  as  far  as  possible,  to  free  it  from  the  habih- 
ments  that  have  hampered  it  in  the  past,  and  if  this 
appears  an  unattainable  goal  at  present,  its  votaries 
may  at  least  aim  at  greater  precision  in  thought  and 
in  observation.  Although  this  doctrine  m.a.y  seem  the 
commonest  of  platitudes,  and  teachers  and  writers  of 
text-books  are  unwearied  in  inculcating  it,  neverthe- 
less precision  in  thinking  and  in  observation  are 
among  the  rarest  qualities. 

2.  Accuracy  of  Observation.  —  The  power  of 
accurate  observation  and  precise  thinking  is  seldom 
acquired,  because  methods  have  become  so  stereo- 
typed that  many  observers  do  not  realise  that  they 
are  fettered  in  the  bonds  of  tradition.  Even  in  the 
writings  of  those  who  claim  to  be  exponents  of  exact 
observation  and  logical  reasoning,  loose  methods  of 
thinking  and  observing  too  often  appear,  even  when 
the  scientist  imagines  himself  supreme,  for  tradi- 
tional teaching  influences  their  minds  and  gives  a 
bias  to  their  deductions.  What  are  called  observa- 
tions are  often  but  a  mixture  of  imperfect 
observation  and  unwarranted  assumption.  While  a 
fact  is  supposed  to  be  recorded,  an  opinion  is  at  the 
same  time  expressed.  As  an  illustration  let  us 
observe  how  the  sj^mptoms  of  a  patient  with  an 
enlarged  liver  are  often  investigated.  The  position 
of  the  liver  having  been  ascertained,  pressure  over  it 
is  found  to  elicit  pain.  The  surgeon  or  physician 
proceeds  to  record  the  "  fact  "  that  the  "  liver  is 
painful  on  pressure,"  and  such  a  description  is 
universally  accepted  as  truthful.  Yet,  if  the  matter 
be  carefully  analysed,  the  statement  will  appear  not 
to  be  a  fact  at  all.     Had  the  statement  been  that  the 


Introduction.  3 

patient  felt  pain  when  pressure  was  made  over  the 
Hver,  then  a  plain  fact  might  have  been  recorded,  if 
the  patient's  testimony  was  reliable.  But  to  say  that 
the  "  liver  was  painful  "  is  to  make  an  assertion  that 
may  or  may  not  be  true,  but  which  is  not  warranted 
by  the  evidence,  seeing  that  pressure  was  being 
exerted  on  the  sensitive  structures  of  the  external 
body  wall,  and  no  attempt  was  made  to  eliminate  the 
possibility  of  the  painful  sensation  being  produced 
by  their  stimulation.  This  tendency  to  embody  war- 
ranted or  unwarranted  assertions  in  the  record  of  a 
fact  is  a  fault  common  among  medical  investigators, 
and  impedes  the  progress  of  medicine.  An  inquirer 
should  keep  his  mind  free  from  bias  and  ready  to 
review  his  most  cherished  beliefs.  What  is  to-day 
accepted  as  axiomatic,  may  be  shown  to-morrow  to  be 
but  a  part  of  the  truth.  The  tendency  to  be  led  by 
tradition  is  very  powerful,  and  it  is  difficult  to  free 
the  mind  from  beliefs  that  have  been  inculcated  with 
the  acquiring  of  knowledge.  In  consequence  of  this 
many  observations  are  fundamentally  untrue,  and 
only  covered  by  a  veneer  of  science.  I  shall  have 
occasion  to  enter  into  some  detail  concerning  the 
relation  of  pain  to  the  viscera,  and  this  inquiiy  will 
reveal  that  the  conception  universally  prevalent  with 
regard  to  the  S3^mptom  is  based  on  tradition  and 
imperfect  observation.  So  much  lias  been  taken  for 
granted  that  the  very  first  step  in  the  examination  is 
often  a  wrong  one.  "  What  do  you  complain  of  ?  " 
asks  the  physician.  "  Pain  in  my  stomach,"  replies 
the  patient,  and  the  physician  too  often  accepts  the 
statement  and  records  that  the  patient's  pain  is  in 
the  stomach.  The  patient  having  some  notion  of  the 
situation  of  the  stomach,  and  finding  the  pain  is  in 


4  Chapter   I. 

this  neighbourhood,  assumes  the  stomach  to  be  the 
seat  of  the  pain,  and  thus,  at  the  very  beginning,  an 
erroneous  notion  is  obtained  which  may  pervert  the 
further  steps  of  the  examination.  The  unproved 
assumption  that  the  mechanism  by  which  visceral 
pain  is  produced  is  similar  to  that  producing  pain  in 
the  external  body  wall  has  led  astray  physiologists 
as  well  as  clinical  observers.  It  is  assumed  that 
stimuli  which  produce  pain  when  applied  to  the 
external  body  wall,  will  likewise  produce  pain  when 
applied  to  the  viscera.  It  is  recognised  that  certain 
nerves  running  from  the  skin  to  the  central  nervous 
system  convey  sensation,  and  are  therefore  called 
"  sensor}^"  From  this  it  has  been  assumed  that  nerves 
proceeding  from  the  viscera  to  the  spinal  cord  have 
the  same  function.  They  are,  therefore,  also  called 
"  sensory,"  whereas,  as  a  matter  of  fact,  there  is  not 
a  single  observation  or  experiment  justifying  such 
an  assumption.  Though  this  is  the  interpretation 
usually  attached  to  the  term  "  sensory,"  physiologists 
do  not  now  consider  that  a  "  sensory  "  nerve  neces- 
sarily evokes  sensation  when  stimulated,  but  use  the 
term  to  imply  an  "  afferent "  nerve  whatever  its 
function  may  be. 

When  making  an  observation  upon  any  symptom 
care  should  be  taken  to  record  nothing  beyond  what, 
strictly  speaking,  the  facts  warrant.  If  our  know- 
ledge tells  us  that  an  organ  is  situated  in  the  neigh- 
bourhood of  the  area  in  which  a  pain  is  felt,  we 
should  not  assert  the  connection  between  the  pain 
and  the  organ  until  we  have  sufficient  evidence  of  the 
nature  of  such  connection.  The  search  for  such 
relations  Avill  reveal  things  unsuspected.  I  may  here 
cite  an  experience  which  occurred  to  me  many  years 


Introduction.  5 

ago.  A  colleague  was  denaonstrating  to  me  the  symp- 
toms ill  a  case  of  gastric  ulcer.  The  pain  was  located 
in  a  small  area  in  the  epigastrium,  which,  the  patient 
said,  could  be  covered  with  the  point  of  a  finger. 
M}^  friend,  commenting  on  this  exact  reference  to  a 
limited  area,  asserted  that  the  pain  was  felt  in  the 
ulcer,  and  were  he  to  push  a  long  pin  through  this 
painful  site  it  would  inevitably  penetrate  the  ulcer. 
I  demurred  to  this,  remarking  that  the  evidence  did 
not  warrant  such  a  conclusion,  that  though  the  pain 
might  be  due  to  the  ulcer,  the  assumption  that  the 
pain  was  felt  in  the  ulcer,  and  that  it  could  be  so 
definitely  localised,  was  not  justified.  To  demon- 
strate this  I  asked  the  patient  to  expire  deeply,  then 
to  draw  a  deep  inspiration.  By  this  procedure 
the  stomach  and  its  ulcer  executed  an  excursion  of  a 
considerable  extent.  But,  though  the  stomach  and 
ulcer  moved,  the  site  of  the  pain  remained  stationary. 
From  this  observation  it  could  be  concluded  that  the 
relation  between  the  ulcer  and  the  pain  was  not  of 
the  kind  usually  assumed.  The  inquiry  into  the 
nature  of  their  relations  has  revealed  some  very 
instructive  features,  which  will  be  dealt  with  in 
speaking  of  the  mechanism  of  pain  and  the  symptoms 
evoked  by  gastric  ulcer.  The  necessity  for  this  warn- 
ing is  illustrated  by  the  remarks  of  observers  who 
iiave  been  testing  the  sensibility  of  the  alimen- 
tary canal.  Where  they  have  succeeded  in  provoking 
a  sensation  by  stimulating  some  portion  of  the 
digestive  tract,  they  have  neglected  some  essential 
features,  such  as  the  exact  situation  of  the  region  in 
which  the  sensation  was  felt,  or  the  manner  in  wliicli 
it  has  spread,  and  have  liastily  assumed  tliat  the  part 
stimulated  possesses  the  sensation  whicli  has  been 


6  Chapter  I. 

evoked.  How  this  assumption  misleads  will  be 
sliOAvn  when  I  deal  with  the  mechanism  by  which 
sensations  are  produced. 

3.  Method  of  Observation. — If  the  nature  of 
any  symptom  is  not  apparent,  all  the  attendant  cir- 
cumstances and  accompanjdng  phenomena  should  be 
the  more  carefully  considered.  The  nature  of  many 
a  striking  phenomenon  may  remain  inexplicable 
until  its  association  with  some  remote,  or  trivial,  or 
transient,  but  better  understood  sjanptom  reveals  its 
true  nature.  This  method  is  in  frequent  use,  as  for 
instance,  when  a  severe  headache  or  retinal  haemor- 
rhage directs  our  attention  to  the  state  of  the  kidneys 
or  a  pain  at  the  knee  leads  us  to  inquire  into  the 
condition  of  the  hip  joint.  The  recognition  of  the 
relations  of  symptoms  so  widely  separated  has  been 
acquired  by  the  observation  of  a  sufhciently  large 
number  of  instances  of  this  continual  association. 
The  occurrence  of  one  symptom  of  a  group  now 
leads  to  the  inquiry  for  the  other  symptoms  that  may 
be  associated  with  it,  and  from  the  experience  thus 
acquired  a  better  view  is  obtained  of  the  diagnostic 
significance  of  particular  symptoms.  When  I  come 
to  deal  with  the  reflex  symptoms  of  visceral  disease 
it  will  be  shown  that,  in  many  cases,  phenomena 
appearing  at  a  distance  from  the  causative  lesion 
give  the  best  clue  to  the  seat  of  the  disease  ;  while 
the  inquiry  into  the  nature  of  the  symptoms  throws 
a  flood  of  light  upon  the  physiological  relation  of 
different  organs. 

4.  The  Value  of  a  Hypothesis. — An  inquirer 
into  the  symptoms  of  disease  will  in  course  of  time 
accumulate  a  large  number  of  more  or  less  isolated 
facts.    Though  these  may  be  provisionally  employed 


Introduction.  7 

in  the  diagnosis  of  disease,  the  observer  may  have  no 
clear  idea  of  their  significance,  nor  of  the  process  by 
which  they  are  produced.  Accordingly,  we  often  find 
the  symptoms  of  some  given  disease  presented  in  the 
form  of  more  or  less  detached  pieces  of  evidence. 
The  value  of  such  indicative  symptoms  will  be  greatly 
enhanced  if  in  all  cases  an  attempt  be  made  to  detect 
the  mechanism  of  their  production,  and  to  correlate 
them  with  the  diseased  process  and  with  one  another. 
To  this  end  it  is  necessary  to  construct  a  provisional 
hypothesis. 

Symptoms,  in  respect  of  concepts,  are  like  the 
materials  used  in  the  construction  of  an  edifice.  We 
may  know  that  detached  they  can  be  used  to  build  a 
house,  but  their  relative  values  and  uses  are  realised 
only  as  we  find  we  can  work  them  into  the  edifice. 
It  is  when  the  symptoms  are  logically  included  in  a 
hypothesis  that  we  clearly  ascertain  their  origin  and 
relative  values.  But  the  construction  of  a  h^^pothesis 
serves  a  useful  purpose  in  many  ways  beyond  giving 
an  approximate  conception  of  the  disease.  It  stimu- 
lates the  search  for  proofs,  and  gives  a  line  to  follow 
in  the  search.  The  progress  of  clinical  medicine  is 
comparatively  slow,  in  great  measure  because  no 
attempt  is  made  to  give  a  clear  conception  of  the 
mechanism  of  disease.  This  has  largely  come  about 
because  the  observer  does  not  trouble  himself  to 
reason  out  the  relations  of  the  symptoms  to  one 
another,  and  to  the  morbid  process  as  a  whole, 
relations  which  can  alone  be  ascertained  by  forming  a 
liypothesis  in  regard  to  their  association.  In  the 
attempt  to  substantiate  the  hypothesis  definite  lines 
for  investigation  will  arise.  The  vakie  of  a  working 
hypothesis  is  that  it  affords  a  guide  and  a  line  of 


8  Chapter  I. 

observation.  Defective,  or  false,  or  useless,  as 
eventual^  it  may  prove  to  be,  yet  it  is  of  advantage 
in,  as  a  step,  directing  our  attention  to  the  relation 
of  sjmiptoms,  and  the  need  for  a  better  interpretation 
of  them.  The  facts  that  belie  a  hypothesis  have 
been  appropriateh'  used  in  building  a  better  one. 
The  atomic  theory  is  now  found  insufficient  to 
explain  the  newer  revelations  of  science,  but 
its  adoption  has  proved  of  immense  service 
in  giving  a  definite  line  for  the  prosecution 
of  investigations  and  in  the  discovery  of  those 
new  facts  that  have  led  to  its  modification. 
In  matters  more  closely  concerning  the  subject  in 
hand  we  have  plenty  of  illustrations.  When  Ross 
drew  attention  to  the  nature  of  sensory  disorders 
in  visceral  disease  he  propounded  the  hypothesis 
that  visceral  pain  was  of  two  kinds,  one  he  called 
"  splanchnic,"  because  he  assumed  that  it  was 
referred  by  the  brain  to  the  site  of  the  lesion  in  the 
organ,  the  other  he  called  somatic,  because  it  was 
referred  to  definite  areas  in  the  external  body  wall. 
This  hypothesis  is  the  one  held  to-day  by  practically 
all  those  who  have  given  attention  to  the  matter  ;  and 
it  has  been  of  no  little  use  in  diagnosis.  In  my  own 
work  it  influenced  me  very  considerably.  At  the  time 
Ross  propounded  this  opinion  I  was  inquiring  into 
the  sensor}^  phenomena  of  visceral  disease,  but  was 
like  a  ship  at  sea  without  compass,  I  had  no  definite 
guide  to  follow.  Then,  with  this  hypothesis  before 
me,  I  proceeded  to  inquire  into  the  facts  concerning 
a  "  splanchnic  "  pain.  The  question  of  the  sensitive- 
ness of  the  viscera  arose,  of  the  function  of  the  nerves 
supplying  them,  and  of  the  relation  of  the  site  of  the 
pain  to  the  lesion.     This  inquiry  brought  to  light 


Introduction.  9 

mam'  other  important  symptoms,  which  either  had 
not  been  recognised,  or  whose  significance  had  not 
been  appreciated,  such  as  the  accompanjdng  hyperal- 
gesia of  the  tissues  of  the  external  body  wall,  and  the 
contractions  of  muscles,  all  having  a  definite  relation- 
ship to  the  viscera  affected  by  means  of  their  nervous 
connection.  These  results,  though  demonstrating 
that  Ross'  hypothesis  was  no  longer  tenable,  were 
brought  to  light  by  means  of  his  hypothesis.  Thus, 
by  suggesting  a  line  of  inquiry  a  hypothesis  may 
bring  many  obscure  S3'mptoms  to  light.  In  investi- 
gating the  manner  in  which  sensation  is  produced  by 
the  viscera,  I  found  that  to  a  great  extent  they  were 
not  susceptible  to  stimuli  in  the  same  manner  as  is 
the  skin.  Thus,  under  certain  circumstances,  the 
ingestion  of  cold  water  into  the  stomach  is  followed 
by  a  sensation  of  cold  felt  in  the  abdomen,  descending 
as  low  as  the  umbilicus.  We  usually  explain  this  by 
saying  that  the  stomach  is  sensitive  to  a  cold 
stimulus.  RiBcognising  that  it  was  strange  that  cold 
should  be  a  sensation  of  which  the  stomach  was 
capable,  I  made  a  series  of  observations  that  showed 
the  cold  sensation  was  in  all  probability  due  to  a 
contraction  of  the  cutaneous  blood  vessels,  and  was 
associated  with  the  goose-skin  eruption.  Further, 
the  evidence  pointed  to  the  fact  that  the  so-called 
goose-skin  sensation  was  coincident  with  a  constric- 
tion of  the  cutaneous  blood  vessels,  and  this  constric- 
tion might  possibly  be  the  cause  of  this  sensation.  1 
do  not  quote  this  observation  as  if  it  settled  the 
question  of  the  sensibility  of  the  stomach  to  cold,  but 
rather  to  show  the  complexity  of  results  from  a  single 
e xperiineiit.  Hertz,  in  liis  Goulstonian  Lectures  on 
the  sensibilitv  of  the  alimentarv  canal,  contests  this 


10  Chapter  I. 

observation,  and  reckons  to  disprove  it,  but  while  I 
am  far  from  believing  that  m}^  explanation  is  beyond 
question,  I  do  not  accept  Hertz's  contradiction,  for  the 
reason  that  he  has  not  considered  the  peculiar  nature 
of  the  "  cold  "  sensation,  and  has  ignored  the  very 
instructive  manner  in  which  the  sensation  spreads. 

Whether  this  explanation  be  the  correct  one  or 
not,  the  attempt  to  prove  the  hypothesis  led  to  the 
discovery  of  other  facts  hitherto  unsuspected,  which, 
trivial  as  they  may  appear,  point  nevertheless  to 
some  fundamental  relation  between  the  viscera  and 
the  external  bod}^  wall  whose  significance  cannot  yet 
be  fully  understood. 

A  hypothesis  based  on  clinical  evidence  may 
serve  as  a  guide  to  physiological  inquiry.  The  hard 
contracted  muscles  present  in  certain  abdominal 
affections  have  never  received  the  attention  they 
merit.  This  contraction,  as  will  be  shown  later,  is  of 
a  peculiar  kind,  and  may  occur  in  a  small  portion 
of  the  muscle.  I  had  called  this  contraction  the 
"  viscero-motor  reflex  "  on  the  hypothesis  that  the 
nerve  supply  to  certain  portions  of  the  muscles  bore 
a  definite  relation  to  the  nerve  supply  of  certain 
viscera,  so  that  the  stimulation  from  a  viscus  would 
produce  contraction  of  a  definite  portion  of  the 
abdominal  musculature.  To  test  this  hypothesis 
Professor  Sherrington  cut  and  stimulated  the  central 
ends  of  certain  nerves  passing  to  the  viscera,  and^ 
in  response  to  such  stimulation,  found  the  abdominal 
muscles  contract  in  a  definite  manner.  The  import- 
ance of  this  observation  will  be  appreciated  later 
when  we  deal  with  the  viscero-motor  reflex.  This 
was,  moreover,  the  first  physiological  demonstration 
of  the  function  of  afferent  sympathetic  nerves. 


Introduction.  1 1 

The  hypothesis  formed  by  chnical  observation 
may  anticipate  the  result  of  physiological  experi- 
ment. In  1891,  as  the  result  of  the  stuch^  of  certain 
common  irregularities  of  the  heart,  I  formed  the 
hypothesis  that  the  ventricle  contracted  at  times 
before,  and  independently  of,  the  auricular  contrac- 
tion. Subsequently  this  was  demonstrated  experi- 
mentally by  Engelmann  in  the  frog's  heart,  and  later 
by  Cushny  in  the  mammalian  heart.  A  hypothesis 
drawn  from  clinical  experience,  though  ultimately 
proved  wrong,  may  stimulate  a  search  which  may 
lead  to  very  important  results.  Thus  in  the  research 
just  alluded  to  I  found  a  large  and  important 
group  of  patients  in  whom  all  evidences  of  the  auri- 
cular systole  had  disappeared,  and  I  speculated  for 
years  as  to  the  cause  of  this  disappearance,  and  built 
up  one  hypothesis  after  another  to  explain  it.  When 
I  found  for  instance  at  the  post-mortem  examination 
that  the  auricle  in  these  cases  was  greath^  distended 
and  thin-walled,  I  put  forth  the  view  that  the  auricle 
was  paralysed.  Further  investigations  to  prove  this 
sliowed  that  the  auricles  in  some  cases  were  hyper- 
trophied,  and  I  was  forced  to  change  my  view,  for  it 
was  evident  that  if  the  auricles  were  hypertrophied, 
they  must  have  contracted.  The  cause  of  the  dis- 
appearance of  the  auricular  activity  was  the  object 
of  research  by  several  investigators,  and  Lewis  finally 
showed  it  to  be  due  to  fibrillation  of  the  auricle,  a 
condition  in  which  the  individual  fibres  of  the 
auricular  wall  no  longer  contract  together  at  regular 
intervals,  but  are  in  incessant  movement,  so  that  tlie 
auricle  stands  still.  The  recognition  of  this  clinical 
condition  and  its  cause  is  one  of  the  most  important 
discoveries  in  the  clinical  pathology  of  the  heart. 


12  Chapter  I. 

5.  The  Parsimony  of  Hypotheses. — In  seeking 
in  any  given  case  for  the  causation  of  a  group  of 
sjauptoms,  however  far  apart  they  may  be  in 
situation,  and  however  diverse  in  character,  it  is  far 
more  probable  that  the  nexus  will  be  found,  not  in 
a  diversity  of  causes  producing  the  symptoms  sever- 
ally, but  in  some  condition  capable  of  producing  the 
group.  The  application  of  this  method,  called  by 
logicians  "  the  law  of  the  parsimony  of  hypotheses," 
should  be  rigidty  applied  in  all  cases  ;  and,  although 
it  may  not  always  be  successful,  the  search  for  a 
connection  between  the  several  phenomena  will  reveal 
many  facts  previously  overlooked  or  neglected,  and 
give  a  guide  to  further  evidence.  A  good  illustration 
of  the  application  of  this  law  is  seen  in  the  examina- 
tion of  cases  with  a  focal  lesion  in  the  brain  or  spinal 
cord.  Certain  lesions  of  small  extent  may  produce 
symptoms  widely  separated,  such  as  paralysis  in 
one  part  of  the  body,  and  sensory  disturbances  in 
another,  while  disturbed  functions  may  be  detected 
in  certain  viscera.  When  the  nerve  supply  of  these 
different  parts  is  considered,  it  will  be  found  that  at 
some  point  the  different  tracts  lie  close  together,  so 
that  it  becomes  fairly  certain  the  lesion  will  be  found 
at  this  place.  The  value  of  this  method  will  be  appre- 
ciated in  dealing  with  visceral  disease,  where  it 
is  shown  that  a  diseased  viscus,  besides  affording 
evidences  of  im'paired  function  and  change  in  form, 
may  also  produce  an  irritation  of  the  spinal  cord, 
resembling  in  many  respects  a  focal  lesion,  and 
inducing  widespread  symptoms  of  great  diversity. 
The  application  of  this  law  becomes  a  matter  of 
considerable  difficulty  when  the  more  prominent 
symptoms  are  due  immediately  to  one  or  more  organs. 


Introduction.  13 

while  the  remoter  causes  He  hidden  in  the  depraved 
function  of  some  other  less  obvious  part.  Thus,  head- 
ache and  convulsions  may  be  the  symptoms  to  arrest 
attention,  but  diseased  kidneys  may  be  the  cause  of 
offence.  Though,  in  this  instance,  it  is  not  possible 
for  us  to  trace  directly  the  connection  between  the 
symptoms  and  the  organ  primarily  at  fault,  never- 
theless, by  the  frequent  association  of  these  pheno- 
mena with  kidney  disease  we  have  discovered  at  least 
the  nexus.  In  the  same  way  hypertrophy  of  the 
heart,  high  blood  pressure,  arterial  degeneration, 
have  been  found  so  frequently  associated  with  kidney 
disease  that  the  primary  cause  of  these  affections  may 
be  attributable  to  the  reaction  of  the  depraved  kidney 
function,  or,  again,  to  some  remoter  cause  lying 
behind  them  all.  Thus  it  will  be  seen  that  in  many 
instances  while  the  direct  relationship  of  the  remoter 
cause  to  the  symptoms  may  not  be  capable  of 
demonstration,  the  frequent  association  of  symptoms 
in  certain  parts  with  a  pre-existing  primary 
lesion  in  some  other  part,  affords  sufficient 
ground  foi'  the  hypothesis  that  this  pre-existing 
lesion  is  an  antecedent  of  the  distant  con- 
sequences, 

6.  Nomenclature.  —  In  the  employment  of 
medical  terms  there  is  no  system  or  m.ethod.  In 
dealing  with  the  nomenclature  of  disease,  names  are 
devised  anyhow.  In  certain  instances,  as  peritonitis, 
endocarditis,  gall-stones  disease,  disease  of  the  mitral 
valves,  the  seat  of  the  disease  is  indicated.  In  other 
instances  a  particular  symptom  or  a  group  of 
symptoms  is  used,  such  as  tachycardia,  exophthalmic 
goitre,  angina  pectoris  ;  while  in  otlier  instances 
again  a  name  derived  from  an  observer  wlio  described 


14  Chapter  I. 

the  symptoms,  such  as  Bright' s  disease,  Cheyne- 
Stokes  respiration,  Brown-Sequard's  paralysis. 
While  such  names  as  these  do,  perhaps,  convey  a 
more  or  less  definite  idea  of  a  particular  disease, 
other  names  are  used  which  may,  indeed,  designate 
some  fairlj^  definite  lesion,  but  more  often  cover  large 
numbers  of  cases  supposed  to  be  akin,  but  of  whose 
nature  we  are  ignorant,  such  as  neurasthenia, 
rheumatism,  neuralgia,  gout.  On  the  face  of  it  the 
ambiguity  of  these  terms  is  unsatisfactory,  but  it  is 
difficult  to  see  how  it  can  be  altered  ;  partly  because 
some  names  by  long  usage  have  become  fixed  ;  partly 
because  provisional  names  must  be  adopted  for 
groups  of  symptoms  of  whose  nature  we  are  mean- 
while imperfectly  informed.  Even  when  precision  is 
supposed  to  be  attained,  and  a  name  given  to  the 
lesion,  as  endocarditis,  peritonitis,  neuritis,  it  may 
yet  happen  that  the  symptoms  are  not  really  the 
outcome  of  the  lesion  whose  name  is  employed.  Such 
sj^mptoms  as  dilatation  of  the  heart,  rapid  or 
irregular  action,  so  often  attributed  to  an  endocar- 
ditis, are  not  evidences  of  an  endocarditis,  but  of  a 
myocardial  affection.  In  the  same  way  lesions  of  the 
myocardium  are  often  ignored  if  there  is  a  murmur 
produced  at  some  orifice  of  the  heart.  Almost 
invariably  the  diagnosis  is  then  based  on  the  noise  the 
heart  happens  to  make,  so  that  we  find  cases  recorded 
as  "  mitral  disease "  when  in  reality  the  accom- 
panying heart  failure  is  due  to  other  conditions.  A 
painful  and  hard  abdominal  wall  is  often  taken 
as  evidence  of  a  peritonitis,  when  no  peritonitis 
exists  ;  or,  again,  a  persistent  pain  along  the  sup- 
posed course  of  a  nerve  with  tenderness  on  pressure, 
often  attributed  to  neuritis,  is  not  infrequently  not 


lnt7'oduction.  15 

due  to  neuritis,  but  is  the  reflex  phenomenon  arising 
from  some  diseased  viscus. 

The  employment  of  symptomatic  names  for 
diseases  may  find  justification  in  some  instances,  but 
may  cause  confusion  in  those  larval  cases  which  do 
not  happen  to  present  the  characteristic  symptoms, 
as,  for  instance,  in  the  early  stage  of  exophthalmic 
goitre.  But,  if  justifiable  in  a  few  cases,  the  employ- 
ment of  a  symptomatic  name,  unless  very  vague,  as 
epilepsy,  is  very  misleading.  Although  a  name 
ought  to  be  restricted  to  the  one  particular  ailment,  it 
is  too  often  used  loosely  to  cover  the  outcome  of 
several  widely  distinct  causes,  as  gastralgia,  tachy- 
cardia, embryocardia,  neuralgia,  albuminuria.  The 
results  of  these  incoherent  methods  of  nomenclature 
are  detrimental  in  several  ways.  Diseases  of.  very 
diverse  nature  are  included  under  one  name.  On 
account  of  the  frailty  of  the  human  mind,  a  certain 
satisfaction  is  given  when  the  name  of  some  sonorous- 
ness is  applied  to  a  malady.  Mental  effort  is 
hard  work,  and  painstaking  inquiry  into  the  natiire 
of  symptoms  may  be  shirked  by  the  use  of  some  fine 
name  that  seems  to  embrace  the  case  under  considera- 
tion. Hence  it  is  that  the  symptoms  present  in 
affections  like  angina  pectoris  are  not  generally 
analysed,  while  an  all-embracing  name  like  neuras- 
thenia, being  turned  from  a  specific  to  any  convenient 
meaning,  serves  for  the  designation  of  many  hetero- 
geneous and  undefined  cases. 

There  seems  to  be  no  logical  way  of  revising 
our  names  until  the  science  of  diagnosis  is  farther 
developed,  so  that  we  must  fain  be  content  with  such 
names  as  are  at  hand.  We  should,  however,  recognise 
and  duly  appreciate  our  limits  in  respect  of  this 


16  Chapter  I. 

imperfect  and  disorderly  nomenclature,  and  con- 
tinually endeavour  to  explain  the  meaning  we  attach 
to  doubtful  names  so  as  to  make  the  use  of  names 
as  precise  as  possible,  in  order  that  like  diseases 
may  be  brought  together  from  those  unhke,  and  our 
classification  be  based  no  longer  on  superficial  and 
accidental  resemblances  but  on  deep  affinities. 


(     17     ) 


Chapter  II. 

CLASSIFICATION    OF    THE    SYMPTOMS    OF 

DISEASE. 

7.  Reflex  Symptoms. 

8.  Purpose  of  Reflex  Symptoms. 

9.  Functional  Symptoms. 

10.  Structural  Symptoms  revealed  by  Physical  Signs. 

11.  The  Relative  Importance  of  Sy7nptoms. 

Disease  is  manifested  by  the  presence  of 
symptoms,  and  these  can  be  classified,  according  to 
the  mechanism  of  their  production,  into  three 
groups : — 

Reflex  Symptoms. 
Functional  Symptoms. 
Structural     S3'mptoms     as     revealed     by 
physical  signs. 

7.  Reflex  Symptoms. — In  the  development  of 
the  body,  organs  are  adapted  for  special  purposes, 
some  for  the  nourishment  and  maintenance  of  the 
economy,  others  for  its  protection.  Tlie  functions  of 
separate  organs  are  pecuUar  to  them,  and  one  organ 
cannot  take  on  the  function  of  anotlier.  It  is  neces- 
sary to  keep  this  distinction  in  mind  in  order  to 
appreciate  the  meaning  and  mechanism  of  symptoms. 
What  is  called  health  is  tlie  harmonious  action  of 
all  the  organs.  Ill-health,  or  disease,  is  the  dis- 
cordant action  of  one  or  more  organs.  There  is  a 
certain    sense    of    "  well-being "    present    in    every 

c 


18  Chapter  II. 

healthy  individual.  Until  the  health  is  impaired  one 
is  barely  conscious  of  having  possessed  it,  and  its  im- 
pairment is  tlie  first  sign  conveyed  to  the  individual 
that  all  is  not  well  with  him.  This  first  sign  is  some 
disagreeable  sensation  arising  from  no  apparent 
cause,  or  brought  on  by  some  event  that  hitherto  had 
caused  no  discomfort.  The  disagreeable  sensation 
may  var}^  from  pain  of  a  severe  type  to  a  slight  im- 
pakment  of  the  sense  of  well-being.  It  may  vary 
also  in  character,  as  pain  in  its  various  forms 
and  degrees,  breathlessness,  vomiting,  exhaustion, 
mental  depression  and  muscular  contraction.  It  will 
be  seen  that  the  production  of  these  symptoms  is  due 
to  the  implication  of  the  nervous  sj^stem,  and 
although  the  possession  of  consciousness  is  necessary 
for  the  perception  of  subjective  sensa^tions,  yet  the 
occurrence  of  these  phenomena  imphes  the  partici- 
pation of  the  nervous  system  in  a  particular  manner. 
The  sensation  of  pain  implies  the  consciousness  to 
perceive  pain  as  well  as  the  involvement  of  the 
special  nervous  mechanism  b}^  which  it  is  produced. 
This  involvement  of  the  nervous  system  in  the  pro- 
duction of  symptoms  requires  special  consideration 
if  we  desire  to  understand  the  true  significance  and 
diagnostic  importance  of  symptoms.  It  is  compara- 
tively rare  that  the  changes  in  the  function  of  an 
organ,  or  in  its  size,  shape  and  position,  lead  to  the 
detection  of  disease  in  the  first  instance,  whereas  the 
presence  of  sj^mptoms  due  to  involvement  of  the 
nervous  S3^stem  are  the  earliest  evidences  and  are 
nearly  always  present.  As  a  matter  of  fact  the  lay- 
man knows  so  little  of  his  anatomy  that  even  a 
serious  anatomical  change  would  often  not  suggest 
a    consultation    with    a    physician,    unless    it    was 


Classification  of  the  Symptoms  of    Disease.     19 

accompanied  by  nerve  symptoms.  While  the  func- 
tional disturbance  of  an  organ  may  interfere  with  the 
nutrition  of  the  nervous  system  and  produce  nervous 
symptoms  directly,  in  the  vast  majority  of  cases  the 
S}'mptoms  are  produced  by  reflex  stimulation. 
Organs  that  are  not  themselves  sensitive  to  painful 
stimuli  liave  provided  in  them  a  mechanism  b}^ 
which  they  can  call  into  play  the  parts  of  the 
economy  that  subserve  the  function  of  pain,  and, 
therefore,  of  protection.  Thus  the  bowels  themselves 
are  insensitive  to  pain,  but  the}^  can  cause  pain  by 
stimulating  the  nerves  that  are  distributed  to  sensi- 
tive structures.  This  is  brought  about  by  the  reflex 
stimulation  in  the  central  nervous  system  of  nerves 
supplying  other  tissues.  Other  reflexes,  as  muscular 
contraction  and  vomiting,  have  also  a  protective 
purpose. 

8.  Purpose  of  Reflex  Symptoms. — To  gain  a 
clear  idea  of  the  mechanism  of  these  reflexes,  their 
purpose  and  meaning  should  be  understood.  To  do 
this  I  put  forward  the  following  hypothesis,  which 
seems  to  account  adequately  for  their  manner  of 
origin,  and  has  much  to  recommend  it  from  a 
developmental  standpoint.  In  the  early  development 
of  animal  life  a  digestive  cavity  is  first  evolved,  then, 
later,  a  rudimentary  circulatory  system  appears.  To 
this  is  added  a  rudimentary  respiratory  system.  To 
co-ordinate  these  different  systems  a  nervous  com- 
munication is  developed.  The  various  organs  are 
protected  first  by  an  insensitive  and,  it  niay  be, 
a  somewhat  unyielding  outer  covering.  As  develop- 
ment proceeds  this  outer  covering  becomes  modified 
in  such  a  manner  as  to  provide  for  both  protection 
and   movement,   hence   arises   the   sensori-muscular 


20  Chapter  II. 

s}  stem.  Protection  is  secured  in  a  twofold  manner, 
first,  by  rendering  the  outer  covering  sensitive  and 
uniting  it  with  muscles  by  means  of  a  reflex  nervous 
system.  Painful  stimuli  excite  consciousness  and  the 
muscles  are  stimulated  to  contract,  so  that  the 
organism,  is  removed  from  the  offending  neighbour- 
hood, or  there  is  interposed  between  the  viscera  and 
the  offending  agent  a  hard  resistant  muscle.  Second, 
by  uniting  the  nerves  from  the  viscera  with  sensory 
and  motor  nerves  of  the  cerebro-spinal  system.,  so 
that  the  m.uscles  of  the  external  body  wall  react  to 
a  stimulus  from  the  viscera.  From  this  point  of  view 
the  primitive  nervous  system  corresponds  with  the 
sympathetic,  while  the  more  recently  developed  sen- 
sori-motor  corresponds  with  the  cerebro-spinal  ner- 
vous system..  This  finds  support  in  view  of  the  fact 
that  pain  is  elicited  only  by  stim.ulation  of  structures 
supplied  by  the  cerebro-spinal  nervous  system,  while 
such  stimuli  as  produce  pain  and  other  sensations  in 
the  skin  and  structures  of  the  external  body  wall  are 
inadequate  to  produce  these  sensations  when  applied 
to  tissues  supplied  by  the  sympathetic  nerves  {see 
page  28).  When  pain  does  arise  from  the  viscera  it 
does  so  by  calling  into  play  the  cerebro-spinal 
system,  of  sensory  nerves,  and  the  pain  is  then 
referred  to  regions  supplied  by  the  cerebro-spinal 
system  of  nerves. 

From  this  point  of  view  it  will  be  found  that 
the  m.ost  striking  symptoms  in  disease  are  produced 
by  reflexes,  sensory,  m.otor  and  organic. 

9.  Functional  Symptoms. — The  economy  is  so 
arranged  that  the  function  of  each  organ  is  neces- 
sary to  the  due  action  of  the  whole.  When,  there- 
fore, an  organ  is  not  acting  efficiently  the  work  of 


Classification  of  the  Symptoms  of    Disease.     21 

all  is  impaired.  As  disease  modifies  the  functions 
of  individual  organs  these  modifications  become 
signs  or  symptoms  of  disease,  hence  it  is  necessary 
to  understand  the  function  of  each  organ,  and  the 
manner  in  which  derangement  of  function  affects  the 
economy  as  a  whole,  or  its  indi\ddual  parts.  It  hap- 
pens not  infrequently  that  the  S3anptoms  which  direct 
attention  to  disease  are  caused  not  directly  by  the 
organ  at  fault,  but  by  the  effects  of  its  impaired 
function  on  parts  remote  from  the  offending  organ. 
From  this  it  will  be  seen  that  a  series  of  phenomena 
may  arise  from  disordered  functions  of  an  organ, 
hence  the  class  of   "  functional  symptoms." 

10.  Structural  Symptoms  revealed  by  Physical 
Signs. — All  the  separate  organs  of  the  body  have 
a  size  and  situation  which  experience  tells  us  are 
normal,  and  any  departure  therefrom  is  presumed 
to  be  an  evidence  of  disease ;  hence  a  class  of 
symptoms  may  arise  due  to  alteration  in  the  size, 
shape,  consistency,  or  position  of  an  organ. 

Structural  symptoms  do  not  arise  until  the 
disease  has  advanced  so  far  as  to  have  modified  the 
organ,  either  by  causing  destruction  of  tissue, 
or  by  rephicing  its  tissue  by  new  formation,  or  by 
altering  its  shape  for  some  cause.  These  symptoms 
then  are  the  signs  of  advanced  disease,  and  often 
indicate  that  the  disease  has  advanced  to  an 
irremediable  si  aire. 

11.  The  Relative  Importance  of  Symptoms.— 
Disease  is  seldom  revealed  by  the  direi't  evidence 
of  modified  function,  but  rather  by  the  effect  of 
depraved  or  deficient  functions  in  other  organs  and 
especially  in  the  central  nervous  system.  W'e  are 
yet  very  ignorant  of  the  evidence  of  the  functions 


22  Chapter  II. 

of  man}^  organs,  particularly  those  glands  which 
have  no  specialised  outlet.  Organs  that  are  special- 
ised for  a  particular  purpose,  as  the  organs  of 
generation,  have  other  functions  which  influence 
growth    and   nutrition. 

Even  when  we  detect  the  presence  of  abnormal 
functions,  it  is  but  rarely  that  this  evidence  of 
derangement  is  the  actual  cause  of  the  symptoms. 
In  kidney  disease  it  is  not  the  presence  of  albumen 
or  the  escape  of  albumen  into  the  urine  that  is  really 
the  serious  fault  of  the  function.  Albuminuria  is 
merely  an  abnormal  condition  which  is  often  asso- 
ciated with  functional  changes  of  such  obscurity 
that  we  know  little  about  them,  but  of  such  potency 
that  we  are  justified  in  attributing  widespread  effects 
to  their  presence.  In  functional  derangement  of  the 
stomach,  though  we  may  detect  certain  abnormalities 
in  the  secretion  as  an  increase  in  the  hydrochloric 
acid,  it  is  not  the  acid  itself  that  is  the  chief  symptom, 
but  the  pain  associated  with  its  presence.  It  is  very 
doubtful  if  the  secretion  of  an  excess  of  hydrochloric 
acid  is  the  real  functional  derangement,  for  it  may  be, 
like  the  albumen,  only  one  result  of  a  complicated 
process.  In  disease  of  the  digestive  apparatus  it  is 
not  always  the  disease  itself  which  produces  the 
symptoms,  nor  the  functional  disturbance,  but  the 
absorption  of  toxic  products. 

From  this  standpoint  the  most  important  class 
of  symptoms  arise  from  the  involvement  of  the 
nervous  system,  where  a  stimulus  arising  in  some 
viscus  passes  to  the  central  nervous  system,  and 
there  acts  on  the  nerves  supplying  other  organs, 
exciting  the  function  peculiar  to  them.  Thus  it  is 
that  we  find  pain,  muscular  contraction  and  vomiting 


Classification  of  the  Symptoms  of    Disease.     23 

excited  by  an  organ  remote  from  these  evidences  of 
nervous  stimulation.  These  reactions  are  not  the 
outcome  of  accidental  purposeless  stimulation,  but 
are'reflexes  arisino;  in  a  very  definite  manner  and  with 
a  definite  purpose.  It  is  necessary  to  recognise  the 
purpose  of  these  reflexes  as  their  intelligent  appre- 
ciation leads  to  the  recognition  of  their  cause, 
whereas  to  look  upon  them  merely  as  purposeless 
evils,  and  as  an  indication  for  something  to 
relieve  suffering  and  discomfort,  tends  to  hamper 
an  opportunity  of  diagnosis  and  rational  treatment. 

The  predominance  of  the  reflex  S3"mptoms  has 
never  been  properly  realised,  with  the  result  that  in 
the  description  of  physical  signs  of  disease  little 
attention  has  been  paid  to  these  manifestations,  and 
no  clear  conception  has  been  made  of  the  nature  of 
the  symptoms.  The  small  part  played  by  functional 
and  structural  signs  or  symptoms  compared  with 
those  of  a  reflex  origin  will  be  appreciated  if,  as  an 
instance,  the  phenomena  of  gastric  affections  be 
considered.  Long  before  any  change  can  be  detected 
in  the  function  or  structure  of  the  organ,  the  reflex 
symptoms  have  been  in  evidence.  It  is  these 
symptoms  that  really  call  attention  to  the  fact  that 
the  stomach  is  diseased,  and  the  patient  may  go  on 
for  years  and  ultimateh'  die  of  the  stomach  com- 
plaint, and  none  but  the  reflex  symptoms  have  been 
capable  of  recognition.  To  a  great  extent  it  is 
towards  the  relief  of  the  reflex  symptoms  that  every 
endeavour  at  treatment  is  directed. 

In  rare  cases  a  physical  sign  of  grave  signifi- 
cance may  be  detected  in  the  absence  of  distinctive 
reflex  symptoms. 


(     24     ) 


Chapter  III. 

PAIN. 

12.  Definition   of    Pain. 

13.  Constitution  of  the   Nervous  System. 

14.  The  Sensitiveness  of  Tissues  to  Painful  Stimuli. 

15.  Mechanistn  hy  which  Pain  is  produced. 

16.  Radiation  of  Pain. 

12.  Definition  of  Pain. — The  due  recognition 
of  the  factors  concerned  in  the  production  of  pain  is 
of  the  first  importance  in  the  study  of  disease.  Not 
only  is  pain  the  most  important  of  complaints,  but 
it  is  the  most  instructive  diagnostic  sign,  for  the 
study  of  its  mechanism  gives  often  the  key  to  the 
best  means  for  attaining  rehef.  The  term  "  pain  " 
used  here  is  easy  to  understand  though  difficult  to 
define.  It  is  beside  my  purpose  to  enter  into  abstruse 
metaphysical  considerations  regarding  the  conscious- 
ness of  pain  and  its  mental  affinities.  Nor  do  I 
include  other  disagreeable  sensations,  which  are 
sometimes  spoken  of  as  pain,  as  when  a  brilliant 
light  or  a  piercing  noise  unpleasantly  affects  the 
sense  of  sight  or  hearing.  The  term  is  limited  to 
that  very  definite  form  of  disagreeable  sensation 
which  everyone  has  experienced,  and  we  all  recognise. 
The  meaning  attached  to  the  term  pain  in  this  book 
may  be  summarised  shortly  as  follows  : — 


Pain.  25 

Pain  is  a  disagreeable  sensation  due  to  stimulation 
of  some  portion  of  the  cerebro-spinal  nervous  system 
and  referred  to  the  peripheral  distribution  of  cerebro- 
spinal sensory  nerves  in  the  external  body  wall. 

13.  Constitution  of  the  Nervous  System. — The 
nervous  system  consists  of  two  great  divisions,  which 
are  distinctly  separated  in  their  functions,  viz.,  the 
cerebro-spinal  and  the  sympathetic  or  autonomic. 
The  former  of  these  divisions  consists  of  the  brain 
and  spinal  cord,  and  the  peripheral  nerves  which  are 
distributed  to  the  external  body  wall  and  subserve 
the  functions  of  sensation  and  muscular  contraction. 
Incorporated  within  the  cerebro-spinal  system  is  the 
other  division,  the  s^'mpathetic  or  autonomic  nervous 
system,  which  includes  the  origin  of  such  nerves  as 
the  vagus  and  the  sympathetic.  The  position  and 
distribution  of  the  efferent  fibres  of  the  autonomic 
s^'stem  is  shown  in  Langley's  diagram  (Fig.  1,  page 
27).  It  will  be  seen  that  this  system  presides  over 
the  functions  peculiar  to  the  different  organs.  While 
much  experimental  work  has  been  done  to  establish 
the  distribution  and  functions  of  the  nerves  that  pass 
from  the  centres  to  the  periphery  (efferent  nerves), 
httle  has  been  done  to  examine  the  nerves  that  pass 
from  tlie  viscera  to  the  central  nervous  system 
(afferent  nerves).  The  reason  for  this  is  that  the 
TUTves  passino;  from  the  organs  to  the  nerve  centres 
afford  httle  direct  evidence  of  their  function,  and 
it  has  not  yet  been  understood  in  what  way  these 
afferent  nerves  react.  In  the  scheme  ]nit  fortli 
liere  for  tlie  production  of  visceral  pain  it  is 
suggested  that  under  certain  circumstances  these 
afferent  nerves  of  the  autonomic  system  convey 
a    stinuilus    to    the    cerebro-spinal     nerves,      and 


26  Chapter  III. 

stimulate  them,  so  that  certain  phenomena  as  pain, 
hyperalgesia,  and  muscular  contraction  in  the  ex- 
ternal body  wall  are  the  evidences  of  stimulation 
by  the  afferent  autonomic  nerves. 

It  is  a  justifiable  inference  from  clinical 
evidence  that  the  centres  of  these  sympathetic  and 
cerebro-spinal  nerves  are  in  close  association.  From 
this  association  it  has  been  possible  to  show  that  the 
afferent  autonomic  nerves  have  a  close  resemblance 
in  their  distribution  to  the  efferent  fibres  represented 
in  Fig.  1. 

14.  The  Sensitiveness  of  Tissues  to  Painful 
Stimuli. — To  appreciate  the  distinction  between 
these  two  divisions  of  the  nervous  system,  and  to 
understand  the  mechanism  by  which  pain  arises  in 
areas  supplied  by  the  cerebro-spinal  nerves,  and  by 
the  autonomic  system  (visceral  pain),  it  will  be 
advisable  to  consider  the  sensibility  of  the  tissues  of 
the  human  body. 

A  great  difference  will  be  found  in  the  suscepti- 
bility of  different  structures.  The  sensibility  to  pain 
varies  widely  in  different  parts  of  the  cutaneous 
surface.  The  deeper  tissues  of  the  external  body 
wall  are  also  sensitive  to  pain,  and  generally  in  a  less 
degree  than  that  of  the  skin,  but  the  relative  sensi- 
tiveness of  parts  is  not  well  understood.  When  we 
consider  the  viscera  we  meet  a  totally  different  state 
of  affairs,  for  in  them  the  tissues  are  insensitive  ta 
stimuli  that  produce  pain  in  the  external  body 
wall.  To  bring  this  clearly  forward,  let  the  reaction 
of  the  tissues  to  some  definite  form  of  stimulation, 
as  pinching  or  pricking  with  a  pin,  be  considered. 
There  will  be  found,  on  a  systematic  examination, 
tissues  where  there  is  a  sense  of  pain  evoked  by 


Pain, 


27 


Sphincter  of  iris  \ 
Ciliarv  muscle.     ) 

Dilator  of  iris.     Orbital   muscle 
Heart.     Blood-vessels     of    mucous 

membrane  of  head. 
Walls   of  gut  from  mouth   to   de- 
scending colon. 

Outgrowths  from  this  region  of  the 
gut  (muscle  of  trachea  and 
lungs ;  gastric  glands,  liver, 
pancreas). 


The  skin  (arteries,  muscles,  glands). 

Blood-vessels  of  gut  betwean 
mouth  and  rectum,  of  lungs 
and  of  abdominal  viscera. 

Arteries    of   skeletal    muscle. 

Muscle  of  spleen,  ureter,  and  of 
internal  generative  organs. 

Walls  of  stomach,  intestine,  gall 
bladder  and  ducts,  urinary 
bladder. 


.Mid-brain  autonomic. 


Bulbar  autonomic. 


Sympathetic. 
(I.  Th.  to  il.  or  III.  L.  in  man.) 


Arteries     of     rectum,     anus     and' 
external  generative  organs. 

Walls  of  descending  colon  to  end 
of  gut. 

Walls  of  bladder  and  urethra. 

Muscle      of      external      generative 
organs. 


Sacra'    autonomic. 
(II.   to   IV.    S.    about  in   man.) 


Fig.  1. 
Diagram  to  show  the  general  origin  and  tli.strilmtionof  efferent  autonomic 
fibres.  By  "muscle"  is,  of  course,  meant  vmstriatod  muscle  only.  By 
the  •'  walls  "  of  a  structure  are  meant  all  the  unstriated  muscle  in  it. 
The  innervation  in  some  cases  is  still  a  matter  of  controversy  (gastric 
glands,  liver,  and  i)rtncreas  ;  vos.sels  of  lungs  ;  small  arterites  of  skeletal 
muscles,  and  arteries  of  the  central  n(>rvous  system).     (Langley.) 


28  Chapter  III. 

pinching  or  pricking,  and  tissues  where  no  sensation 
is  felt.  Wlien  these  tissues  are  placed  in  two 
separate  groups,  it  will  be  found  that  in  the  group 
where  the  tissues  are  sensitive  to  pain  the  nerve 
supply  comes  from,  the  cerebro-spinal  nervous  system, 
while  the  group  where  there  is  no  sensation  of  pain 
is  supplied  solely  by  the  autonomic  system  of 
nerves. 

Seeing  that  the  viscera  are  insensitive  to  stimuli 
that  produce  pain  in  tissues  supplied  by  cerebro- 
spinal nerves,  and  seeing  that  pain  can  arise  from 
visceral,  stimulation,  it  follows  that  the  mechanism 
by  which  pain  is  produced  must  be  different  in  these 
two  systems. 

15.  The  Mechanism  by  which  Pain  is  pro- 
duced on  stimulation  of  Cerebro-spinal  Nerves. 
— There  is  good  ground  for  assuming  that  there  are 
special  nerves  for  the  conduction  of  pain,  with 
special  organs  at  the  periphery  capable  of  receiving 
the  special  stimulation.  The  conduction  of  such 
pain  stimulus  is  by  the  afferent  nerves  passing  into 
the  central  nervous  system  by  the  posterior  nerve 
roots. 

When  a  stimulus  is  applied  to  the  peripheral 
organ  in  the  skin,  the  nerve  not  only  conveys  to  the 
centre  of  consciousness  the  sensation  of  pain,  but 
also  indicates  the  locality  in  which  the  stimulus  is 
produced.  This  power  of  localisation  varies  in  its 
exactitude,  but  pain  is  always  referred  to  a  point 
somewhere  in  the  neighbourhood  of  the  stimulation. 

In  the  course  of  its  passage  from  the  skin  to 
the  brain  the  nerve  may  be  subjected  to  stimulation, 
and  if  the  stimulation  be  suflficient  to  provoke  a 
response,  pain  will  be  felt,  and  it  will  be  localised  not  at 


Pain.  29 

the  place  stimulated  but  in  the  field  of  the  peripheral 
distribution  of  the  nerve.  The  pressure  of  a  growth  on 
the  trunk  of  a  nerve,  or  disease  affecting  the  posterior 
root  ganglia,  as  occurs  in  herpes  zoster,  or  lesions  in 
the  spinal  cord,  as  in  locomotor  ataxia,  or  irritation  in 
the  brain  itself,  all  give  rise  to  pain  when  a  pain 
nerve  is  stimulated,  and  the  pain  is  referred  to  the 
peripheral  distribution  of  the  nerve  in  each  case. 

The  reason  for  this  pain  being  referred  to  a 
part  remote  from  the  seat  of  the  irritation  is  due  to 
the  fact  that  when  stimulated  to  activity  every 
nerve  gives  rise  to  its  peculiar  function.  If  it  be  the 
optic  nerve  then  it  gives  rise  to  a  sensation  of  light ; 
if  it  be  the  auditory  nerve  then  to  the  sensation  of 
sound  ;  if  it  be  a  pain  nerve  then  to  the  sensation  of 
pain  referred  to  the  peripheral  distribution  of  the 
nerve. 

16.  Radiation  of  Pain. — The  consideration  of 
the  localisation  of  pain  and  the  manner  in  which  it 
spreads  throws  a  great  deal  of  light  upon  the 
mechanism,  of  pain.  It  often  happens  that  when 
there  is  severe  pain  due  to  an}^  cause,  such  as  from  a 
whitlow,  or  a  sm.all  abscess  by  the  side  of  a  finger 
nail,  that  the  pain  is  felt  to  spread  up  the  finger  to 
the  hand,  and,  it  may  be,  to  the  arm.  Not 
only  so,  but  the  skin  and  deeper  tissues  in 
the  neighbourhood  of  the  disease  are  often 
very  tender  on  pressure.  It  might  seem,  and  it 
is  usually  accepted,  that  this  is  due  to  the  irritation 
of  the  nerve  ends  in  the  neiglibourliood  of  the 
lesion  by  some  obscure  process.  But  this  is  not  the  ex- 
planation. The  real  nature  of  the  disturbance  can  be 
inferred  when  the  nerves  stimulated  by  the  disease 
])rocess  are  in  close  association  in  the  brain  or  s]iinal 


30  Chapter  III. 

cord  with  nerve  fibres  supplying  structures  at  some 
distance.  To  take  the  most  common  instance,  the 
fifth  cranial  nerve  supplies  the  teeth  and  also  the 
skin  of  the  cheek.  In  toothache  there  may  not  only 
be  the  pain  referred  to,  and  great  sensitiveness  of, 
one  tooth,  but  the  pain  may  be  felt  along  the  jaw  and 
in  the  cheek.  Not  only  may  the  pain  be  felt  in  the 
cheek,  but  the  skin  of  the  cheek  may  become  ex- 
tremely tender  to  touch,  so  that  to  gently  brush  the 
hair  causes  a  definite  sensation  of  pain.  A  still 
more  striking  instance  is  recorded  by  Professor 
Sherrington.  He  states  that  "  by  applying  a  mus- 
tard leaf  over  the  front  of  the  upper  part  of  the 
sternum,  I  can  produce  in  myself  the  sensation  of  a 
patch  of  unpleasantly  tingling  character  referred  to 
the  inner  side  of  each  upper  arm,  just  above  the 
inner  condyle." 

Neither  in  this  case  nor  in  that  of  the  toothache 
could  continuity  of  the  peripheral  structures  be  the 
cause.  The  same  stimulation  produced  the  pain  in 
widely  separated  parts.  If  we  inquire  into  the  nerve 
supply  the  matter  becomes  clear.  The  second 
thoracic  nerve  supplies  the  skin  of  the  upper  part 
of  the  chest  and  of  the  inner  side  of  the  upper  arm. 
While  the  peripheral  ends  of  the  nerves  supplying 
the  upper  part  of  the  chest  and  the  inner  side  of  the 
upper  arm  are  widely  apart,  their  centres  in  the 
spinal  cord  are  intimatety  associated,  so  that  when 
a  violent  stimulus  from  the  periphery  reaches  the 
spinal  cord  it  affects  the  nerve  cells  in  its  neighbour- 
hood, which  in  this  case  happen  to  be  those  supplying 
the  upper  arm.,  and  thej^  react  accordmg  to  their 
nature,  and  give  rise  to  pain  referred  to  their  peri- 
pheral distribution.     In  the  same  manner  the  nerves 


Pain.  31 

supplying  the  teeth  and  the  skin  of  the  cheek  meet 
in  the  centre  of  origin  of  the  fifth  cranial  nerve,  and 
the  stimulation  of  the  fibres  from  the  teeth  affect 
the  fibres  supplying  the  cheek. 

In  the  diagnosis  of  symptoms  it  is  of  the  highest 
importance  to  appreciate  both  the  nerve  suppty  of 
the  part  in  which  the  pain  is  felt,  and  the  relation  of 
these  nerves  to  others  in  the  central  nervous  system. 
The  manner  in  which  the  pain  spreads  and  the 
appearance  of  other  phenomena  due  to  central 
stimulation  provide  the  clue. 


(     32     ) 


Chapter  IV. 

VISCERAL    PAIN. 

17.  The    Function  of    Afferent    Sympathetic    Nerve 

Fibres. 

18.  Insensitiveness  of  the    Viscera  to  stimulation. 

19.  Sensitive    Tissues  of  the   External  Body   Wall. 

20.  Testicular  Pain. 

21.  Artificial   Production  of     Visceral   Pain. 

22.  Relationship  of  the  Site  of  Pain  to  the  Site  of  the 

Lesion. 

23.  Mechanism     by     which     Pain    is    produced    in 

Visceral  Disease. 

24.  Referred  Pain. 

25.  Radiation  of    Visceral  Pain. 

26.  Pain  the  only  Sensory  Reflex  in   Visceral  Disease. 

27.  Lennander^s   Observations. 

17.  The  Function  of  Afferent  Sympathetic  Nerve 
Fibres. — Bearing  in  mind  the  view  that  the  effective 
stinaulation  of  any  part  ot  a  nerve  fibre  from  the 
periphery  to  the  brain  will  result  in  the  evidence  of 
its  peculiar  function,  the  cause  of  pain  in  visceral 
disease  becomes  easy  to  understand.  In  the  normal 
processes  of  life  a  succession  of  stimuli  is  continually 
passing  from  the  viscera  by  the  afferent  nerves  to 
the  spinal  cord,  and  reacting  upon  the  nerves 
supplying  muscles,  blood  vessels  and  other  struc- 
tures. These  processes  are  so  conducted  that  they 
normally  give  rise  to  no  appreciable  sensation. 


Visceral  Pain.  33 

If,  however,  on  account  of  a  morbid  j)rocess  in 
any  viscus  an  increased  stimulus  passes  b}^  the 
afferent  nerves  to  the  spinal  cord  this  stimulus  may 
be  of  a  kind  that  affects  neighbom'ing  nerve  cells,  and 
these  nerve  cells  react  according  to  their  functions — 
a  sensory  cell  by  producing  pain,  a  motor  cell  by 
contraction  of  certain  muscles,  a  secretory  nerve  by 
increased  flow  of  its  peculiar  secretion,  and  so  forth. 
When  such  stimulation  affects  a  sensor}'  nerve,  pain 
arises,  which  is  referred  to  the  peripheral  distribu- 
tion of  the  nerve  so  stimulated. 

18.  Insensitiveness  of  the  Viscera  to  ordinary 
stimulation. — I  have  already  pointed  out  that 
the  viscera  are  insensitive  to  those  methods  of 
stimulation  that  produce  pain  in  the  external  body 
wall.  Haller  demonstrated  that  in  animals  the 
viscera  could  be  cut  and  burnt  while  the  animal 
unconcernedly  ate  its  food.  Harve}^  described  the 
insensitiveness  of  the  heart,  and  a  great  number  of 
observers  have  testified  to  the  fact  that  other 
viscera  are  totally  insensitive  to  stimulation.  Per- 
sonally I  have  stimulated  nearly  every  organ  of  the 
body,  and  have  failed  to  elicit  pain  by  procedures 
which  elicited  pain  when  applied  to  the  external 
body  wall.  It  is  only  in  rare  instances  that  the 
opportunity  is  afforded  of  demonstrating  the  insen- 
sitiveness of  the  viscera  by  their  direct  stimulation 
in  the  conscious  subject.  As,  however,  it  is  often 
attempted  to  demonstrate  the  tenderness  of  organs 
by  stimulating  them  through  the  external  body  wall, 
it  is  necessary  to  comprehend  the  sensitiveness  of 
the  structures  so  stimulated,  for  it  often  happens 
that  the  pain  produced  by  stimulation  of  one 
structure  is  referred  to  another. 


34  Chapter  I  V. 

19.  Sensitive    Tissues    of    the    External    Body 
Wall. — If  we  take  the  abdominal  wall  we  find  three 
great  laj^ers  endowed  with  exquisite  sensibility  to 
pain.     The  first  of  these,  the  skin,  I  need  not  dwell 
upon,  save  to  point  out  how  its  sensibility  frequently 
becomes  increased  in  visceral  disease,  and  how  this 
increased    sensitiveness    is    united    to    an    exalted 
muscular  reflex.     The  second  of  these  sensitive  layers 
is  the  voluntary  muscular  system  best  observed  in  the 
flat  muscles  of  the  abdomen.     It  is  the  sensitiveness 
of   this   muscular   layer   which   is   most   commonly 
exalted  in  visceral  disease,  its  sensibility  being  very 
readily  increased.     Muscular  hj^peralgesia  is  such  a 
striking  phenomenon,  is  so  frequently  present  and 
plaj^s    such    an   important    part   in   the   protective 
mechanism,  that  it  is  astonishing  to  find  it  almost 
universally    overlooked.     One    can    read    elaborate 
treatises  devoted  to   special  organs,  in  which  this 
symptom  is  the  most  striking  and  the  most  instruc- 
tive feature,  but  its  presence  is  nevertheless  over- 
looked or  misinterpreted.     In  an  ordinarj^  case  of 
stomach  ulcer,  appendicitis,  gall-stone,  renal  colic, 
or  enlarged  liver,  if  one  notes  the  tenderness  of  the 
abdominal  wall,  and  observes  how  this  deep  tender- 
ness extends  far  beyond  the  site  of  the  organ  affected, 
one  can  appreciate  the  nature  and  significance  of  this 
sensitive  layer.     With  a  little  care  one  will  be  able  to 
distinguish  this  muscular  hyperalgesia  from  cutaneous 
hyperalgesia  and  from  hyperalgesia  of  the  deeper 
tissues.     The  third  sensitive  la3^er  is  one  of  which 
anatomists  and  physiologists  were  quite  ignorant  till 
recently,  though  it  has  long  been  suspected  from 
clinical    observations.      It    is    the    laj^er    of    loose 
connective    tissue    lying    immediately    outside    the 


Visceral  Pain.  35 

peritoneum.  I  suspected  its  presence  for  a  long  time  as 
I  could  frequently  get  exquisite  tenderness  in  pushing 
my  fingers  between  the  recti  muscles,  for  instance  in 
cases  of  gastric  ulcer,  the  stomach  not  being  affected 
by  the  pressure.  Its  existence  can  be  shown  in  an 
operation  for  the  radical  cure  of  hernia  under  cocaine 
anaesthesia.  The  skin  and  muscles  can  be  cut 
through,  and  the  patient  experiences  no  pain.  When 
the  loose  connective  tissue  outside  the  peritoneum  is 
gently  torn  through  the  patient  may  experience  most 
exquisite  pain.  After  the  peritoneum  is  exposed  it 
can  be  incised,  its  visceral  layer  scratched  and  after- 
wards stitched,  and  the  patient  feels  no  pain.  I  have 
verified  this  observation  on  several  occasions. 
Ramstrom  has  made  a  careful  histological  exam- 
ination of  the  abdominal  wall  of  man  and  other 
mammals,  and  showed  that  this  region  is  richly 
endowed  with  nerves  and  nerve  endings,  the  nerves 
being  derived  from  those  which  supply  the  muscles  of 
the  abdoniinal  wall.  This  observation  may  probably 
afford  a  clue  to  the  confused  statements  that  exist  in 
regard  to  the  sensitiveness  of  the  peritoneum.  I  can 
only  say  this,  that  I  have  on  numerous  occasions  in 
the  course  of  operations  scratched  and  cut  the  serous 
surface  of  the  peritoneum  on  conscious  subjects  with- 
out any  analgesic,  local  or  general,  and  have  never 
known  the  slightest  sensation  elicited.  One  can 
understand,  however,  that  the  inflamed  peritoneum 
and  adhesions  might  readily  affect  this  remarkable 
nervous  layer.  Peritonitis,  however,  so  readily 
produces  muscular  hyperalgesia  and  tonic  muscular 
contractions  (viscero-motor  reflex),  that  the  pain  and 
tenderness  are  demonstrably,  in  tlie  niajority  of  cases, 
of  spinal  origin  {see  Chapter  XVIII.). 


36  Chapter  I  V. 

With  the  recognition  of  these  sensitive  struc- 
tures— frequentty  rendered  exquisitely  sensitive  to 
painful  stimuli  in  visceral  disease — it  will  be  under- 
stood how  impossible  it  is  to  judge  of  the  sensitiveness 
of  the  viscera  from  external  exploration.  When, 
therefore,  we  find  the  surgeon  or  physician  demon- 
strating the  sensitiveness  of  any  viscus,  it  will  be 
realised  that  he  is  in  reality  stimulating,  in  his 
examination,  those  extremely  sensitive  structures  of 
the  external  abdominal  wall,  and  referring  the  pain 
he  elicits  to  an  organ  that  is  totally  insensitive  to 
any  such  stimulation. 

20.  Testicular  Pain. — On  the  other  hand,  one 
cannot  always  be  sure  of  the  source  of  pain,  as 
when  pressure  is  applied  over  a  movable  kidney  or 
readily  palpated  abdominal  tumour.  That  pain 
arises  on  pressure  on  a  viscus  is  undoubted,  but  the 
pain  does  not  seem  to  arise  from  the  direct  stimula- 
tion but  by  reflex  stimulation  of  a  sensory  cerebro- 
spinal nerve.  This  can  be  demonstrated  in  the  case 
of  the  testicle.  In  ordinary  cases  when  the  cord  is 
short  the  pains  felt  on  applying  pressure  to  the 
testicle  are  not  readily  differentiated.  If,  however, 
an  individual  with  a  long  cord,  where  the  testicle 
hangs  down  a  long  way  from  the  groin,  be  examined, 
the  pains  resulting  from  pressure  on  the  testicle  can 
be  separately  recognised.  In  such  an  instance  a  pain 
is  felt  at  once  readily  localised  over  the  point  of 
pressure.  A  few  seconds  later  another  pain  is  felt 
gradually  increasing  in  intensity,  and  gradually 
passing  away  and  referred  to  the  groin.  Accom- 
panying the  pain  there  is  sometimes  a  sensation  of 
faintness,  very  slight  with  light  pressure,  but 
evidently    of    the    same    nature    as    the    intense 


Visceral  Pain.  37 

depression  following  on  a  blow  on  the  testicle. 
This  depression  and  pain  are  similar  to  those  which 
are  evoked  by  pressure  on  the  kidney  and  ovary. 
Concerning  the  first  of  these  pains  when  it  is  felt 
at  once  and  referred  to  the  place  of  stimulation,  a 
curious  question  arises  bearing  on  the  sensibility  of 
serous  membranes.  As  I  have  already  pointed  out, 
I  have  scratched  the  serous  surfaces  of  both  visceral 
and  parietal  peritoneum  and  pleura,  and  elicited  no 
sensation  of  pain,  but  exquisite  pain  may  be  elicited 
by  scratching  the  tunica  vaginalis.  In  certain  cases 
in  tapping  a  hydrocele,  if  the  testicle  be  gentty  held 
with  one  hand  and  the  visceral  layer  of  the  tunica 
vaginalis  lightly  scratched  with  the  canula,  the 
patient  at  once  experiences  pain  and  refers  the  pain 
unerringly  fco  the  region  scratched.  However  lightly 
the  stimulus  is  made  no  sensation  is  experienced 
beyond  that  of  pain,  resembling  in  this  respect  the 
sensibility  of  the  cornea.  As  demonstrating  the 
difference  between  the  sensibility  of  the  tunica 
vaginalis  and  the  peritoneum,  I  cite  the  following 
experience.  A  patient  consulted  me  with  his 
scrotum  greatly  enlarged  and  full  of  fluid,  which  I 
took  to  be  a  hydrocele.  I  tapped  him  and  tested  the 
sensibihty  of  the  testicle.  I  found  the  patient  did 
not  feel  pain  when  I  scratched  what  I  took  to  be 
liis  tunica  vaginalis.  I  scratched  rather  roughly,  yet 
no  painful  sensation  was  experienced.  Finding  I 
coukl  not  reduce  the  whole  of  the  swelling  I 
coiu'hided  that  the  case  was  not  one  of  hydrocele, 
and  on  operating  I  found  the  case  was  one  of 
omental  liernia  with  the  sac  distended  by  peritoneal 
fluid.  What  I  had  been  scratching  was  the 
peritoneum. 


38  Chapter  I  V. 

As  the  tunica  vaginalis  and  the  peritoneum 
have  the  same  origin  it  appeared  strange  that  there 
should  be  this  difference  in  sensation,  until  on 
inquiry  I  found  that  a  cerebro-spinal  nerve  is 
distributed  to  the  tunica  vaginalis,  viz.,  a  twig  of  the 
genital  branch  of  the  genito-crural  nerve.  The  tunica 
vaginalis  is  the  only  sensitive  serous  membrane 
covering  an  organ  that  I  have  detected,  and  it  is  the 
only  one  to  which  a  branch  of  a  cerebro-spinal  nerve 
has  been  traced. 

In  certain  cases  the  tunica  vaginalis  becomes 
hyperalgesic  [see  page  183).  Professor  Waterston 
tells  me  that  the  visceral  layer  of  the  tunica 
vaginalis  is  not  of  the  same  origin  as  the  parietal, 
but  is  looked  on  as  a  persistence  of  the  germinal 
epithelium.  This  may  have  some  bearing  on  the 
sensibility  of  the  testicle,  and  ray  suggestion  as  to 
the  nature  of  the  testicular  sensitiveness  is  therefore 
provisional. 

21.  Artificial  Production  of  Visceral  Pain. — 
It  is  a  curious  fact  that  although  the  belief  is  so 
universally  held  that  the  viscera  are  endowed  with 
"  sensory  "  nerves,  and  that  physiologists  refer  to 
afferent  sympathetic  nerves  as  "  sensory  "  in  func- 
tion, not  a  single  authentic  observation  has  been 
rendered  to  show  that  the  viscera  have  a  direct 
sensibility  of  their  own,  i.e.,  a  sensibility  derived 
from  the  possession  of  nerves  which  when  stimulated 
produce  a  sensation.  Of  course,  a  great  deal 
depends  on  what  is  considered  evidence,  many  people 
being  perfectly  satisfied  if  they  elicit  pain  b}^  pressing 
over  an  organ.  Phj^siologists  have  interpreted 
certain  movements  as  an  expression  of  pain  after 
stimulating  afferent  sympathetic  nerves.     But  this 


Visceral  Pain.  39 

does  not  prove  that  pain  was  evoked  nor  does  it  prove 
that  the  pain  was  a  direct  pain,  nor  does  it  show  in 
what  situation  the  pain  was  felt,  for  the  location  of 
the  pain  is  the  key  to  the  problem.  It  is  therefore 
necessary  in  investigating  this  matter  to  be  sure  of 
the  tissue  stimulated,  and  the  region  in  which  the 
resultant  pain  is  felt.  It  is  because  of  the  absence 
of  the  specification  of  the  locus  of  the  pain  that  many 
otherwise  important  observations  are  rendered  of 
little  value  in  respect  to  this  investigation. 

That  pain  can  be  produced  bj^  visceral  stimula- 
tion is  easily  demonstrated  if  one  employs  an 
adequate  stimulus.  It  is  now  many  years  since  I 
pointed  out  that  the  most  violent  pains  of  which  we 
are  conscious  are  associated  with  hollow  muscular 
organs,  and  that  by  producing  violent  contraction 
of  a  hollow  viscus  pain  can  be  elicited.  The  easiest 
way  to  do  this  is  to  give  a  distending  enema  of  warm 
water,  and  to  retain  the  enema  until  painful  peri- 
stalsis results.  That  the  pain  is  really  due  to  the 
contraction  of  the  muscle  wall  of  the  bowel  is  evident 
from  the  fact  that  with  the  relaxation  of  the 
sphincter  during  the  pain  the  contents  of  the  bowel 
are  expelled  with  considerable  force,  and  the  pain  at 
the  same  time  subsides.  Here  it  is  evident  that  a 
considerable  portion  of  the  descending  colon  and 
rectum  must  have  contracted,  but  the  pain  is  not  felt 
along  the  position  occupied  by  these  structures,  but, 
in  the  majority  of  people,  it  is  referred  across  the 
middle  line  immediately  above  the  pubis. 

The  following  observation  demonstrates  an 
exactly  similar  series  of  facts  : — 

T  liad  occasion  to  resect  a  small  portion  of  the 
small  intestine  in  a  conscious  subject,  for  umbilical 


40  Cha'pter  IV. 

fistula,  whose  abdominal  cavity  I  laid  open.  He 
refused  to  take  an  anaesthetic,  and  no  analgesic,  local 
or  general,  Avas  administered.  There  were  numerous 
peritoneal  adhesions,  and  while  I  cut  and  tore  these 
the  patient  was  unconscious  of  any  sensation.  I  cut 
and  stitched  the  serous  surfaces  of  parietal  and  vis- 
ceral peritoneum,  I  tore  adhesions  from  the  hver,  I 
cut  and  sutured  the  bowel  and  mesentery,  and  no 
sensation  was  felt.  After  preparing  tlie\ipper  part 
of  the  bowel  it  was  A\Tapped  in  a  warm  cloth  and 
laid  on  one  side.  During  the  subsequent  steps  the 
patient  frequently  moaned.  I  asked  him  if  he  felt 
pain,  and  he  replied  that  he  did.  I  asked  him  where 
he  felt  the  pain,  and  he  indicated  with  his  hand 
that  it  was  across  the  middle  line  at  the  level  of  the 
umbihcus.  I  at  first  felt  that  it  might  be  due  to  the 
part  that  I  was  manipulating,  but  the  pain  was 
intermittent.  Chancing  to  look  at  the  prepared 
upper  part  of  the  bowel  that  lay  on  the  left  side  of 
the  abdomen,  I  observed  that  every  few  minutes  a 
peristaltic  wave  passed  over  the  lower  portion  of  it, 
and  when  this  occurred  the  patient  moaned  in  pain. 
I  made  certain  that  the  pain  was  connected  with 
the  peristaltic  wave,  and  I  produced  the  peristalsis 
several  times  by  lighth"  pinching  the  bowel.  I  also 
made  sure  the  patient  had  no  doubt  as  to  the  place 
in  which  it  was  felt,  with  the  result  that  here  before 
my  eyes  was  the  cause  of  the  pain  which  the  patient 
felt,  and  yet  the  patient  referred  the  site  of  the  pain 
Avith  precision  to  an  area  ten  inches  or  twelve  inches 
away  from  the  contracting  bowel. 

An  objection  has  been  taken  by  Hirst  to  the 
explanation  of  this  observation.  He  contends  that 
the  reference  of  the  pain  to  the  middle  line  was  due 


Visceral  Pain.  41 

to  the  brain  referring  the  sensation  of  its  "  average 
position."  The  average  locahsation  theory  is  but  an 
attempt  to  explain  obscure  symptoms  without 
taking  the  trouble  to  inquire  into  all  the 
evidence. 

22.  The  Relationship  of  the  Site  of  the  Pain 
to  the  Site  of  the  Lesion. — For  mam-  years  I  have 
kept  notes  of  the  position  in  which  pain  was  felt  in 
a  great  variety  of  diseases,  and  in  course  of  time  I 
have  been  able  to  identify  the  exact  site  of  the  lesion 
in  cases  that  come  to  operation,  or  to  post-mortem 
examination.  The  conclusion  arrived  at  from  the 
consideration  of  these  cases  was  that  the  situation 
of  the  pain  did  not  as  a  rule  directly  afford  any  clue 
to  the  situation  of  the  lesion,  but  when  the  situation 
of  the  pain  was  immediately  over  the  lesion,  other 
evidences  showed  that  the  pain  was  not  felt  in  the 
organ,  but  referred  to  the  sensory  nerves  in  the 
external  body  wall.  I  shall  quote  the  proofs  of  this 
conclusion  presently,  but  here  I  will  describe  the 
theory  which  explains  the  peculiar  nature  of  visceral 
pain. 

23.  The  Mechanism  by  which  Pain  is  produced 
in  Visceral  Disease. — Wlien  a  nerve  that  ter- 
minates in  a  sense  organ  is  stimulated  in  any  part  of 
its  course  from  the  periphery  to  the  brain,  a  stimu- 
lation is  given  to  the  brain  of  a  kind  similar  to  what 
would  liave  happened  if  the  peripheral  end-organ 
had  been  stimulated.  Thus  the  stimulation  of  any 
part  of  the  optic  nerve  or  auditory  nerve  gives  rise 
to  the  sensation  of  light  or  of  sound.  In  the  same 
manner  if  a  sensory  nerve  be  stimulated  in  any  part 
of  its  course  through  the  brain,  spinal  cord,  or  trunk 
of  the  nerve,  the  resultant  sensation  is  referred  to 


42  Chapter  IV. 

the  peripheral  distribution  of  the  nerve  in  the  exter-^ 
nal  body  wall.  As  already  remarked,  in  the  normal 
processes  of  life,  a  succession  of  stimuli  is  con- 
tinually passing  by  the  afferent  nerves  to  the  spinal 
cord,  and  continuously  plajdng  upon  the  efferent 
nerves  that  run  to  muscles,  blood  vessels,  and  so 
forth,  maintaining  what  we  call  "  tone  "  in  muscles 
and  blood  vessels.  These  processes  are  conducted  so 
that  they  give  rise  to  no  appreciable  sensation.  If, 
however,  a  morbid  process  in  a  viscus  gives  rise  to  an 
increased  stimulus  of  the  nerves  passing  from  the 
viscus  to  the  spinal  cord,  this  increased  stimulation 
affects  neighbouring  centres,  and  so  stimulates  sen- 
sory, motor,  and  other  nerves  that  issue  from  this 
part  of  the  cord.  Such  stimulation  of  a  sensory 
nerve  will  result  in  the  production  of  pain  referred 
to  the  peripheral  distribution  of  the  nerve,  whose 
spinal  centre  is  stimulated,  so  that  the  visceral  pain  is. 
really  a  viscero-sensory  reflex.  If  the  increased 
stimulus  affects  a  motor  centre,  then  a  contraction  of 
the  skeletal  muscle  results,  and  thus  is  produced  the 
viscero-motor  reflex  (see  diagram.  Fig.  4,  page  87). 

The  two  following  cases  illustrate  these  points  : 
A  female,  aged  36.  For  a  couple  of  years  the  patient 
had  suffered  from  violent  attacks  of  abdominal  pain, 
I  never  saw  her  during  an  attack,  but  the  following 
was  the  condition  found  after  a  severe  attack.  The 
abdominal  wall  over  the  right  iliac  fossa  was  hard 
and  rigid,  due  to  the  contraction  of  the  muscles^ 
When  the  skin  was  lightly  pinched  there  was  no 
increased  tenderness  but  pressure  on  the  rigid 
muscle  was  very  painful.  The  right  thigh  was 
slightly  bent  upon  the  abdomen,  and  could  be 
extended    only   with    difficulty,    owing  to   a   tonic 


Visceral  Pain.  43 

contraction  of  the  psoas  muscle.  On  walking  a  short 
distance  the  patient  developed  a  stoop,  due  to  the 
increased  contraction  of  this  muscle.  When  the 
erector  spinae  muscles  on  both  sides  were  lightly 
grasped  in  the  lumbar  region  those  of  the  right  side 
were  found  very  painful.  There  were  frequent  calls 
to  micturition,  the  quantity  passed  at  each  time 
being  small,  and  containing  no  abnormal  constituents. 

This  description  of  the  sj'mptoms  was  confirmed 
by  ]\Ir.  Caird,  who  operated  on  the  patient.  The 
following  conditions  were  found  at  the  operation : — 
When  the  abdominal  cavity  was  opened  nothing 
abnormal  could  be  detected.  The  parietal  peri- 
toneum was  perfectly  healthy,  and  only  healthy  coils 
of  intestine  were  exposed  to  view.  On  separating 
these  coils  the  appendix  was  found  red  and  inflamed, 
adherent  by  soft  red  bands  to  the  caecum,  and 
separated  from  the  bladder  by  coils  of  uninflamed 
intestine.  The  appendix  was  removed,  and  the  patient 
made  a  good  recovery,  though  it  was  a  couple  of 
months  before  all  the  symptoms  quite  disappeared — 
the  last  symptom  to  go  being  the  slight  contraction 
of  the  psoas  muscle,  which  became  more  contracted 
on  walking  a  short  distance. 

Grouping  the  reflex  phenomena  in  this  case  we 
recognise  (1)  A  viscero-motor  reflex  in  the  muscular 
contraction  of  the  transversalis  abdominis,  the 
oblique  and  psoas  muscles  ;  (2)  a  viscero-sensory 
reflex  in  the  increased  sensitiveness  of  the  sensory 
nerves  supplying  the  muscles  over  the  right  iliac 
fossa  and  the  erector  spinse  ;  and  (3)  an  irritability 
of  the  bladder  resulting  in  frequent  micturition. 

It  is  manifest  from  the  condition  found  at  the 
operation  tliat  these  very  definite  symptoms  could  not 


44  Chapter  I  V. 

have  been  caused  by  the  impHcation  of  the  structures 
m  the  inflammation  which  affected  the  appendix.  If, 
on  the  other  hand,  we  look  into  the  origin  of  the 
nerves,  motor  and  sensory,  that  supply  these  muscles 
and  the  sj^mpathetic  supplying  the  bladder,  we  find 
that  they  all  arise  from  a  limited  area  in  or  near  the 
twelfth  thoracic  and  first  or  second  lumbar  spinal 
segments.  It  becomes,  then,  a  justifiable  inference 
that  the  stimulus  that  produced  these  symptoms 
arose  in  the  appendix,  and  that  this  stimulus  was 
conveyed  from  the  appendix  by  its  sympathetic  nerve 
supph"  to  the  spinal  cord,  and  therefore  that  the 
appendix  is  supplied  by  a  sympathetic  nerve  that 
joins  the  cord  at  the  segments  mentioned.  In  Fig.  1, 
page  27,  it  is  shown  that  the  nerve  to  the  bladder 
leaves  the  cord  at  two  places — with  the  sympathetic 
nerves  from  the  upper  lumbar  region,  and  with  the 
visceral  sacral  nerves.  In  the  case  just  cited  the 
frequent  micturition  showed  an  increased  sensitive- 
ness of  the  bladder  and  so  we  can  infer  that  the 
afferent  fibres  of  the  bladder  reach  the  spinal  cord 
at  the  upper  lumbar  region. 

In  the  following  observation  a  description  is 
given  of  the  effects  produced  by  a  stimulation  of  the 
cord  as  definite  as  Siuy  plwsiological  experiment. 

Renal  Colic. — A  man,  aged  30,  had  suffered  for 
a  year  from  occasional  attacks  of  renal  colic,  and  one 
attack  had  been  followed  by  haematuria.  He  was  a 
very  intelligent  man,  and  I  told  him  to  note  every 
particular  during  an  attack.  The  following  is  a 
summary  of  his  statement — the  original  statement 
being  illustrated  by  the  patient  placing  his  hand 
over  the  regions  mentioned :  The  pain  suddenly 
seizes  him  with  great  severity  in  the  right  lumbar 


Visceral  Pain.  45 

region,  then  after  a  few  minutes  it  strikes  into  the 
front  of  the  abdomen  over  the  ihac  fossa.  Then  tlie 
belly  becomes  hard  and  rigid.  The  pain  then  strikes 
down  into  the  internal  part  of  the  groin,  the  testicle 
is  felt  to  be  drawn  up,  and  the  pain  then  shoots 
into  the  testicle.  The  facts  here  described  were 
corroborated  by  him  in  a  few  subsequent  attacks, 
each  attack  invariably  pursuing  the  same  sequence. 
My  notes  made  after  an  attack  describe  an  indefinite 
area  of  cutaneous  hyperalgesia  over  the  iliac  fossa, 
hardness  and  rigidity  of  the  abdominal  muscles  over 
the  right  iliac  fossa,  with  great  tenderness  on 
pressing  over  the  muscles  and  on  pressing  the  right 
testicle  and  the  right  erector  spinae  muscles  in  the 
lumbar  region.  Here  the  symptoms  pointed  to  a 
localised  stimulation  of  the  spinal  cord  at  the  origin 
of  the  sensory  nerves  supplying  the  skin  over  the 
right  iliac  region,  the  testicle  and  the  abdominal  and 
erector  spinae  muscles,  and  at  the  origin  of  the  motor 
nerves  supplying  these  abdominal  muscles  and  the 
cremaster  muscle.  These  nerves  issue  from  the  spinal 
cord  by  the  twelfth  thoracic  and  first  lumbar  roots. 
The  area  stimulated  in  the  cord,  it  will  be  observed, 
is  not  confined  to  one  segment,  but  passes  along  a 
path  which  affects  only  a  limited  portion  of  several 
segments — a  curious  feature  to  which  I  shall  revert 
in  dealing  with  the  radiation  of  pain. 

In  regard  to  the  immediate  cause  of  the  symp- 
toms, 1  reasoned  that  there  was  a  calculus  lodged 
somewhere  about  the  pelvis  of  the  kidney,  and  that 
its  presence  acted  like  a  foreign  bod}-,  sending  a 
wave  of  strong  peristalsis  down  the  ureter,  the 
gradual  passage  of  the  peristalsis  sending  strong 
stimuli  to  a  descending  region  of  the  spinal  cord. 


46  Chapter  I  V. 

The  fact  that  the  pain  always  started  at  the  same 
place  indicated  that  the  stone  remained  fixed  in  its 
position,  a  view  confirmed  by  the  fact  that  there  was 
never  ?iny  evidence  of  the  calculus  having  reached  the 
bladder.  The  reasons  I  had  for  the  assumption  that 
the  stone  remained  in  the  pelvis  will  be  gathered  as 
I  develop  my  argument.  An  X-ray  photograph 
failed  to  reveal  the  stone.  Such  being  my  opinion  I 
sent  the  patient  to  Mr.  Wright,  who,  agreeing  with 
my  diagnosis,  operated  in  1903,  and  found  a  small 
calculus  about  the  size  of  a  pin's  head  adherent  to 
the  apex  of  a  calyx,  opposite  the  junction  of  the 
middle  and  lower  third  of  the  kidney.  This  was 
removed,  and  the  patient  made  a  good  recovery,  and 
has  remained  quite  free  from  all  symptoms. 

24.  Referred  Pain.— The  reason  why  the  pain 
is  referred  to  portions  of  the  body  so  far  apart  is 
because  in  the  course  of  development  the  tissues  that 
in  a  low  scale  of  life  immediately  covered  the  organ 
had  been  displaced.  Thus,  the  pain  felt  in  the 
testicle  in  renal  colic  is  due  to  the  fact  that  in  its 
journey  down  to  the  scrotum  the  coverings  of  the 
testicle  receive  a  twig  from  the  first  lumbar  nerve, 
and  when  the  centre  of  this  nerve  in  the  spinal  cord 
is  stimulated,  as  in  renal  colic,  the  pain  radiates  to 
the  testicle.  In  renal  colic  one  never  finds  the  skin 
of  the  scrotum  hyper  algesic,  but  always  the  deep 
covering  of  the  testicle,  because  the  scrotum  is  sup- 
plied by  the  sacral  nerves,  while  the  ureter  and 
testicle  are  supplied  by  lumbar  nerves. 

This  view  is  the  one  adopted  by  practically  all 
to  account  for  what  is  called  "  referred  pain."  Ross 
described  visceral  pains  as  of  two  sorts,  "  splanchnic  " 
pain  in  the  organ,  and  "  somatic  "  pain  referred  to 


Visceral  Pain.  47 

some  part  of  the  body  wall  remote  from  the  organ. 
But  when  the  so-called  "  splanchnic "  pains  are 
critically  examined  they  will  be  found  to  be  of  the 
same  nature  as  somatic  pain. 

25.  Radiation  of  Visceral  Pain. — Perhaps  the 
best  evidence  as  to  the  true  nature  of  ^^sceral  pain 
is  found  in  the  manner  in  which  pain  spreads.  No 
attempt  has  been  made  by  writers  to  appreciate  the 
meaning  and  significance  of  the  spreading  of  pain. 
It  is  usually  assumed  that  the  pain  is  in  the  affected 
viscus,  so  that  we  find  such  statements  as  a  "hyper- 
sensitive "  gall-bladder  and  a  "  tender  liver,"  while 
the  pain  of  an  inflamed  gall-bladder  is  "  diffused  over 
a  large  area  along  and  below  the  margin  of  the  liver." 
In  what  tissues  was  this  widely  diffused  pain  felt  ? 
If  the  pain  were  in  the  gall-bladder,  how  comes  it 
that  it  was  felt  in  a  region  more  extensive  than  that 
occupied  by  the  gall-bladder  ? 

The  diffusion  of  pain  over  a  wider  area  than 
that  occupied  b}'  the  organ  in  which  the  stimulus 
producing  the  pain  originates  can  be  proved  in 
many  ways  to  be  due  to  an  extension  of  the  irritation 
affecting  the  central  ends  of  sensor}^  nerves  in  the 
spinal  cord  as  has  been  described.  Thus  the  exten- 
sion of  the  painful  area  is  frequently  associated  with 
hyperalgesia  of  the  tissues  of  the  external  body  wall. 
The  pain  is  often  found  to  radiate  along  pecidiar 
areas,  inexplicable  unless  we  recognise  the  relation- 
ship in  the  spinal  cord  of  the  nerves  supplying  these 
areas,  as,  for  instance,  when  the  pain  of  angina 
pectoris  passes  from  the  front  of  the  chest  into  the 
axilla  and  down  the  arm — that  is  to  say,  into  areas 
supplied  by  contiguous  nerve  roots  (third,  second, 
and  first  thoracic  nerves)  ;    or  the  pain  may  appear 


48  Chapter  I  V. 

at  a  distance  from  the  affected  organ  and  gradualljr 
approach  it  till  it  is  felt  in  the  tissues  covering  the 
organ,  as  when  in  angina  pectoris  the  pain  may  at 
first  be  confined  to  the  arm,  but  with  increasing^ 
severity  radiates  to  the  front  of  the  chest. 

An  excellent  illustration  of  the  referred  pain  is 
seen  in  cases  where  the  lesion  is  in  the  tissues 
supplied  by  the  phrenic  nerve.  The  phrenic  nerve 
passes  out  of  the  spinal  cord  with  the  fourth  cervical 
nerve,  receiving  sometimes  small  branches  from  the 
third  and  fifth  cervical  nerves.  It  is  distributed  to 
the  diaphragm,  the  liver,  and  the  gall  ducts.  The 
sensory  nerves  from  the  fourth  and  fifth  cervical 
nerves  are  distributed  to  the  skin,  over  the  top  of  the 
shoulder  and  down  the  outside  of  the  arm.  In  a  few 
cases  of  diaphragmatic  pleurisy  (sometimes  with 
basal  pneumonia)  the  patient  has  felt  severe  pain 
over  the  top  of  the  shoulder  on  the  affected  side.  On 
rare  occasions  I  have  found  a  patch  of  cutaneous 
hyperalgesia  on  the  shoulder  {see  Fig.  15,  page  216). 
In  gall-stone  disease,  shoulder  pain  is  a  not  infre- 
quent complaint,  and  the  pain  may  extend  from  the 
top  of  the  shoulder,  and  down  the  outside  of  the 
upper  arm.  It  may  persist  here  with  such  severity 
that  the  casual  condition  may  be  overlooked,  and  the 
case  looked  upon  as  one  of  "  neuritis."  The  expulsion 
of  a  gall-stone  may  be  followed  by  instant  and  per- 
manent relief.  In  many  instances  pain  of  real  severity 
may  be  experienced  and  the  pain  may  be  in  some 
part  near  the  organ  causing  the  pain,  and  no  hyperal- 
gesia may  be  detected.  Such  instances  cannot  claim 
to  settle  the  question  whether  the  pain  is  direct  or  re- 
ferred. If,  however,  a  careful  search  is  made  in  all  cases,, 
some  will  be  found  which  exhibit  this  hyperalgesia. 


Visceral  Pain.  49 

26.  Pain  the  only  Sensory  Reflex  in  Visceral 
Disease.— There  is  one  pecuHar  and  puzzling 
feature  about  the  reflex  stimulation  set  up  by  a 
visceral  affection,  namely,  that  pain  is  practically 
the  only  sensation  evoked.  I  shall  show  later  that 
the  stimulus  from  the  organ  on  reaching  the  spinal 
cord,  if  of  an  adequate  strength,  will  pass  on  to 
neighbouring  nerve  cells,  and  stimulate  motor  and 
secretor}'  nerves,  as  well  as  the  pain  nerves.  But  it 
is  not  clear  why  the  stimulation  should  not  affect 
the  nerves  that  subserve  otlier  forms  of  sensation  as 
touch,  heat,  and  cold.  The  ingestion  of  cold  into  the 
stomach  does,  under  certain  circumstances,  give  rise 
to  a  sensation  of  cold,  and  I  have  tried  to  explain 
that  by  another  hypothesis,  but  apart  from  this  the 
stimulus  from  any  viscus  does  not  produce  cold  or 
any  sensation  but  that  of  pain.  The  only  explana- 
tion I  can  suggest  is  that  for  other  sensations,  apart 
from  pain,  a  special  receptor  organ  is  necessary,  for 
we  know  that  in  the  skin  there  are  special  spots 
which  are  alone  susceptible  to  heat  or  cold,  and  unless 
the  stimulation  reached  the  central  nervous  S3'stem 
by  the  special  organ  at  the  periphery  for  receiving 
these  sensations,  the  stimulation  of  these  nerves  at 
higher  levels  gives  no  response.  On  the  other  hand,  in 
disease  of  the  central  nervous  system  other  sensations 
may  arise,  such  as  formication,  which  are  supposed 
to  be  due  to  stimulation  of  particular  nerve  fibres. 

27.  Lennander's  Observations. — The  observations 
of  Lennander  are  in  agreement  with  those  I  have 
made,  and  I  quote  here  a  typical  illustration  from 
Barker's  translation  of  Lennander's  book.  Jt  will  be 
seen  that  pain  is  sometimes  produced  from  stimulation 
of  the  viscera,  as  in  pulling  on  the  gall-bladder,  but 

E 


50  Chapter  IV. 

such  methods  of  stimulation  do  not  give  a  clear  idea 
of  the  tissues  that  gave  rise  to  the  pain,  whether,  for 
instance,  the  pulling  affected  the  sensitive  outer  layer 
of  the  peritoneum ;  nor  is  there  any  indication  of  the 
locality  to  which  the  pain  was  referred. 

Hast  and  Meltzer  object  to  the  conclusions 
drawn  by  Lennander  from  his  observations,  because 
Lennander  had  used  injections  of  cocaine,  which, 
they  say,  induced  a  certain  degree  of  anaesthesia, 
and  diminished  the  sensibility  of  the  viscera.  I 
do  not  think  this  objection  valid,  for  m\^  results 
agree  with  Lennander' s,  and  most  of  my  patients 
had  no  anaesthetic  of  any  kind. 

'  Parietal  Peritoneum  ;  Gall-bladder  ;  Adhesions 
between  Abdominal  Viscera. — We  learn,  from  the 
following  case  and  others,  that  the  parietal  peri- 
toneum derives  its  sensibility  from  the  intercostal 
nerves  in  the  subserosa.  If  such  a  nerve  be  divided, 
the  parietal  peritoneum  on  the  distal  side  becomes 
insensitive  over  an  area  corresponding  to  the 
distribution  of  its  twigs,  which  is  not,  however, 
large.  This  depends  upon  the  fact  that  the  areas  of 
distribution  of  different  twigs  are  common  to  both. 
In  case  ...  it  will  be  seen  that  a  gall-bladder  which 
was  adherent  to  the  omentum  and  transverse  colon 
and  whose  mucous  membrane  showed  marked 
catarrh — it  contained  a  gall-stone  as  large  as  a  plum 
—  was  entirely  without  sensation.  The  patient 
had  no  feeling  either  of  pain  or  touch  during  all 
the  manipulations  of  the  operation  necessary  for 
a  cholecystotomy  with  so-called  "  water-tight 
drainage." 

'  As  it  seemed  desirable  to  produce  adhesions 
between  the  anterior  surface  of  the  liver  and  the 


Visceral  Pain.  51 

abdominal  wall  in  the  neighbourhood  of  the  gall- 
bladder, the  serosa  of  the  former  was  destroyed  over 
a  considerable  area  by  various  means,  such  as  silver 
nitrate,  thermo-cautery,  scratches  mth  a  needle,  etc. 
The  surface  of  the  liver  proved  to  be  destitute  of  all 
sensation  either  of  pain  or  touch.  It  was  the  same 
when  the  anterior  border  of  the  liver  was  pinched 
between  the  finger  and  thumb.  The  adhesions  also 
between  the  gall-bladder,  the  omentum  and  meso- 
colon were  insensitive,  as  also  were  the  two  last 
structures. 

'  F.,  aged  64,  admitted  December  3rd,  1900. 
Biliary  colic,  with  tedious  fever  for  fifteen  months. 
Great  weakness  and  diffuse  bronchitis  in  both  lungs. 
In  the  urine  both  albumen  and  granular  casts. 
General  anaesthesia  contra-indicated.  December  3rd, 
J  cgr.  morphia  and  Schleich's  infiltration.  Notes  : 
"  The  gall-bladder  was  adherent  to  the  transverse 
mesocolon,  and  moderately  full  of  dark  green  bile. 
The  mucous  membrane  was  red  and  swollen,  but 
without  ulcers  ;  one  calculus,  the  size  of  a  plum, 
lying  in  the  entrance  of  the  c^^stic  duct." 

'  Microscopically  and  bacteriologically  the  bile 
showed  B.  coli  C07n.,  and  another  rod-like  organism 
which  reacted  to  Gram's  stain,  but  could  not  be 
further  differentiated. 

'  During  the  whole  operation  the  patient  re- 
mained perfectl}^  quiet,  and  to  each  question  in 
regard  to  pain  gave  a  clear  and  intelligent  answer. 

'  Notes  specially  directed  to  the  question  of  pain 
during  cholecystotomy  with  "  water-tight  drainage  " 
of  the  gall-bladder.  The  omentum  was  stitched  to 
the  latter.  Iodoform  gauze  packing  between  liver 
and  abdominal  wall.     The  first  incision  was  parallel 


52  Chapter  IV. 

to  the  right  rectus,  and  at  its  outer  border.  Division 
of  the  aponeuroses  of  the  obhque  produced  pain. 
How  far  the  pain  was  present  at  ever}^  point  or 
only  where  small  nerve-twigs  were  divided  is  uncer- 
tain. Nevertheless  the  pain  which  follows  division 
of  the  aponeurosis  maj^  clearly  be  severe.  After 
infiltration  between  the  aponeurosis  of  the  external 
oblique  and  between  the  internus  and  transversalis 
muscles,  these  structures  can  be  divided  without  any 
expression  of  pain  on  the  part  of  the  patient,  but 
on\.j  those  parts  involved  in  the  artificial  oedema. 
The  same  holds  for  the  transversalis  muscle  both 
before  and  after  the  infiltration  after  Schleich. 

'  On  division  of  a  nerve  in  the  abdominal  Avail  a 
momentarj^  pain  was  felt. 

'  In  the  area  supplied  by  the  divided  nerve  no 
pain  was  felt  in  the  parietal  serosa,  either  when 
incised  or  pinched  with  arter}"  forceps,  etc.,  but 
outside  of  this  area  severe  pain  was  produced  by  the 
same  stimuli.  After  infiltration  of  the  extraperi- 
toneal areolar  tissue  the  p.  parietale  became  insensi- 
tive over  the  rather  limited  area  efficiently  charged 
b}'  the  fluid.  In  the  other  parts  not  reached  by  the 
ansesthetic  the  pain  on  manipulation  of  the  p. 
parietale  was  alwaj's  severe. 

'  Stretching  of  the  abdominal  wound  with 
rounded  hooks  produced  severe  pain. 

'  When  the  peritoneum  had  been  opened  the 
mesial  part  of  the  same  was  found  to  be  insensitive 
(the  nerves  supplying  it  had  been  gradual^  divided), 
but  the  outer  part  of  the  peritoneum  was  still  very 
sensitive  to  pain.' 


Visceral  Pain. 


53 


Palpation  within  the  belly — of  the  gall-bladder  and  its 

neighbourhood      .  .  . .  .  .  .  .  .  .  . .      Pain. 

Gall-bladder — gentle  palpation  of  the  fundus  so  that  the 

walls    of    the    sac    were    pressed    together    without 

stretching  or  contact  with  the  abdominal  wall       .  .      Xo  sensation. 
Drawing  forward  of  the  gall-bladder  .  .  .  .  Pain, 

Three  artery  forceps  were  applied  to  the  serosa  of  the 

organ  .  .  .  .  .  .  .  .  .  .  . .  .  .      Xo  sensation. 

Silver  nitrate  to  the  serosa  of  the  organ .  .  .  .  .  .      Xo  sensation. 

Drying  of  the  serosa  with  gauze     .  .  .  .  .  .  .  .      Xo  sensation. 

Burning  of  the  serosa  of  gall-bladder  with  the  thermo- 
cautery      .  .  . .  .  .  . .  .  .  .  .  .  .      Xo  sensation. 

Powerful    compression   of   the   gall-bl«idder   between   the 

fingers         .  .  .  .  .  .  .  .  .  .  .  .  .  .      Xo  sensation. 

Drying  of  the  surface  of  the  liver  with  gauze    .  .  Xo  sensation. 

Cauterisation  of  the  surface  of  the  liver  with  silver  nit. 

thermocautery,  and  scratching  with  needles  . .      Xo  sensation. 

Drawing  forward  of  gaU-bladder  and  division  of  adhesions 

with  thermo -cautery       .  .  .  .  .  .  .  .  .  .      Pain. 

Division    of    adhesions    between    the    gall-bladder    and 

omentum  with  thermocautery  .  .  .  .  .  .      Xo  sensation. 

Division  or  cauterisation  of  adhesions  between  the  trans. 

m.  colon  and  gall-bladder  behind        .  .  .  .  .  .      Xo  sensation. 

P.  Peritoneum  drawn  with  hooks  on  midline  of  the  wound     Xo  sensation. 
On  outer  side  of  the  same   .  .  .  .  .  .  .  .  .  .      Severe  pain. 

Introduction  and  removal  of  gauze  between  p.  parietale 

and  omentum       .  .  .  .  .  .  .  .  . .  .  .      Pain. 

Opening    the    abdominal    wound    in    order    to   introduce 

gauze  packing      .  .  .  .  .  .  .  .  .  .  .  .      Severe  pain. 

Grasj)ing   the   whole   thickness   of   the   gall-bladder   with 

Pean's  forceps      .  .  .  .  .  .  .  .  .  .  .  .      Xo  sensation. 

Puncture  and  aspiration  of  the  gall-bladder         .  .  .  .      Xo  sensation. 

Incision  of  gall-bladder  with  thermo-cautery        .  .  .  .      Xo  sensation. 

Palpation  of  its  interior  with  the  finger   .  .  .  .  .  .      Xo  sensation. 

Compression    of    gall-bladder    upon    the    large    calculus 

behind        .  .  .  .  .  .  .  .  .  .  . .  .  .     Pain. 

Extraction  of  the  .stone  with  a  large  spoon  introduced 

with  the  finger    .  .  .  .  .  .  .  .  .  .  .  .      Xo  sensation. 

Plugging  of  the  gall-bladder  with  iodoform  gauze  as  far 

as  cystic  duct      .  .  .  .  .  .  .  .  .  .  .  .      Xo  sensation. 

'■  Tobacco-pouch  "  suture  round  the  opening  in  the  viscus 

with  a  large  needle  for  ""  water-tight   '  drainage    .  .      Xo  sensation. 
Introduction  of  a  drain    tube    and  closure  of  the  above 

suture,  lasting  a  minute  .  .  .  .  .  .  .  .      Xo  sensation. 

Removal  of  tampons  between  omentum  and  transverse 

colon  ....  .  .  .  .  .  .  . .  .  .  .  .     No  sensation. 

Introduction    and    removal    of    gauze    tampons    between 

liver  and  i)arietal  peritoneinn  .  .  .  .  .  .  .  .      Severe  jjain. 

Suture  of  omentum  round  gall-bladder      .  .  .  .  .  .      Xo  sensation. 

Ligature  of  vessel  in  wall  of  gaU-bladder  .  .  .  .      Xo  sensation. 

Comjiression  of  tran.sversi  colon  between  fingers  .  .      Xo  sensation. 

A|>plication    and    knotting   of  sutures   between    the   gall-     Little  if  any 

bladder  and  j).  ])arietale  of  the  niedivun  side  of  wound  pain. 

On  the  outer  side       .  .  .  .  .  .  .  .  .  .  .  .      Severe  pain. 

I'lugging  on  the  inner  side  of  the  wound  .  .  .  .      Slight  pain. 

On  the  outer  side       .  .  .  .  .  .  .  .  .  .  .  .      Severe  pain. 

A|)plicati()n  of  Pean's  forceps  on  either  side  of  the  wound 

showed  the  same  results. 


(     54     ) 


Chapter  V. 

VISCERAL    VAm— continued. 

28.    Objections  to  the    Referred    Nature    of     Visceral 
Pain. 

28.  Objections  to  the  Referred  Nature  of 
Visceral  Pain. — In  putting  forward  the  view  that 
the  pains  arising  from  the  viscera  are  not  felt  in  the 
organ,  but  are  referred  to  the  peripheral  distribution 
of  cerebro-spinal  nerves  in  the  external  body  wall,  I 
had  opposed  to  me  the  opinion  of  practically  aU 
people,  whether  they  had  studied  the  subject  or  not. 
It  is,  therefore,  necessary  to  consider  the  reasons  why 
such  unanimous  opinion  should  have  been  held,  and 
to  show  the  grounds  on  which  I  based  a  contrary 
view. 

It  is  now  recognised  that  pains  arising  from  an 
organ  may  be  referred,  but  it  is  even  now  held  that 
there  are  pains  felt  in  the  organ  itself,  and  that  the 
organ  can  become  sensitive,  i.e.,  the  organs  give 
rise  to  a  "  somatic "  or  referred  pain,  and  to  a 
"  splanchnic  "  or  pain  felt  in  the  organ. 

The  evidence  for  this  splanchnic  pain  is  sup- 
posed to  be  found  in  the  fact  that  the  organ,  though 
insensitive  in  its  normal  state,  may,  under  certain 
circumstances,  become  sensitive.  The  evidence  for 
this  is  supposed  to  be  found  in  the  fact  that  pressure 
over  the  organ  causes  pain.     Thus,  the  stomach  is 


Visceral  Pain — continued.  55 

said  to  be  tender  in  gastric  ulcer,  because  pressure 
applied  over  the  epigastrium  is  very  painful.  In 
the  same  wa}^  pressure  over  an  enlarged  liver  or 
inflamed  pleura  causes  pain.  As  this  method  of 
investigation  ignores  the  heightened  sensibility 
(hyperalgesia)  of  the  tissues  covering  the  external 
body  wall  (as  the  skin  and  muscles),  it  is  no  argu- 
ment in  favour  of  the  sensibility  of  the  organ. 
This  matter  is  dealt  with  more  fully  in  Chapter  VI., 
where  I  describe  in  detail  the  hyperalgesia  of  the 
skin  and  of  the  muscles.  While  in  the  vast  majority 
of  cases  the  pain  arising  from  pressure  applied  to  an 
organ  through  the  external  body  wall  will  be  found 
to  be  due  to  stimulation  of  the  structures  of  the  ex- 
ternal body  wall,  there  are  exceptional  cases  where 
the  pain  cannot  be  attributed  to  such  structures.  It 
has  been  shown  in  the  case  of  the  testicle,  that  the 
pain  is  felt  not  in  the  organ  but  in  the  groin,  i.e.,  it 
is  a  referred  pain,  the  pressure  being  an  adequate 
stimulus  to  produce  this  form  of  pain.  In  rare  and 
exceptional  cases,  as  in  a  movable  kidney,  or  an 
abdominal  tumour,  I  have  not  been  able  to  satisfy 
myself  as  to  the  real  nature  of  the  pain  elicited  by 
pressure,  and  this  matter  requires  further  investiga- 
tion, if  possible,  when  the  organ  or  tumour  is 
exposed. 

Another  reason  for  assuming  that  the  pain  is 
in  the  organ  is  the  fact  that  a  pain  is  felt  in  the 
position  where  our  knowledge  tells  us  the  organ  is 
situated,  and  other  evidences  abundantly  justify  the 
view  that  the  pain  did  arise  from  this  organ.  This 
seems  to  most  people  to  be  conclusive  evidence  of 
the  sensibility  of  tlie  organ,  but  there  has  to  be 
exercised  a  very  cautious  discretion  before  accepting 


56  Chapter    V. 

such  a  view.  The  assurance  in  all  cases  is  not  forth- 
coming that  the  organ,  though  diseased,  and  though 
causing  the  pain,  is  situated  exactly  where  the  pain 
is  felt.  I  have  already  referred  to  the  fact  that  if 
the  organ  be  moved  the  pain  does  not  shift,  as  in 
gastric  ulcer,  for  though  the  stomach  may  be  made 
to  move  up  and  down  by  deep  respiratory  move- 
ments, the  pain  remains  stationary.  Another  reason 
against  assuming  the  pain  to  be  in  the  organ  is 
that  the  pain  may  extend  to  regions  beyond  the  limit 
of  the  organ.  This  fact,  though  observed,  has 
never  received  the  consideration  it  merits  in  connec- 
tion with  the  locating  of  the  pain.  Thus,  a  pain  may 
be  described  as  being  felt  in  an  organ  and  extending 
in  various  directions  beyond  the  limits  of  the  organ. 
I  have  endeavoured  to  explain  why  it  does  this  by 
pointing  out  how  it  is  caused  by  an  extension  of 
the  stimulus  in  the  spinal  cord  to  the  nerve  supply  of 
regions  adjacent  to  the  nerves  supplying  the  offend- 
ing viscus  (page  47).  In  certain  cases  this  extension 
to  regions  beyond  the  site  of  the  organ  has  been 
recognised.  Thus  in  angina  pectoris  the  pain  may 
start  in  the  chest  and  radiate  to  the  left  arm.  This 
is  spoken  of  as  a  pain  starting  in  the  heart  and 
shooting  into  the  arm — the  pain  in  the  heart  being 
of  the  nature  of  a  localised  pain  in  the  organ,  while 
the  pain  in  the  arm  is  a  referred  pain.  To  such  an 
argument  as  this  one  cannot  alwa^^s  bring  direct  and 
demonstrable  objections,  but  if  all  the  evidence 
present  in  certain  cases  be  considered  it  will  be 
found  that  the  reasonable  conclusion  to  draw  is  that 
the  pain  in  the  chest  and  the  pain  in  the  arm  arise  in 
the  same  manner.  On  page  96  I  show  that  the  nerves 
supplying  the  chest-wall  are  in  close  association  in 


Visceral  Pain — contiyiued.  57 

the  spinal  cord  with  those  supplying  the  arm,  and 
that  both  sets  of  nerves  are  thus  closely  associated 
Avith  the  origin  of  the  sympathetic  nerves  supplying 
the  heart.  The  question  naturally  arises,  is  the  pain 
in  the  arm  not  merely  an  extension  of  that  felt  in  the 
chest,  and  due  to  an  extension  of  the  stimulation  in 
the  spinal  cord  ?  When  all  the  facts  in  certain  cases 
are  considered,  then  an  affirmative  answer  to  such  a 
question  can  be  reasonably  given.  Thus  the  pain 
may  be  felt  with  greater  intensity  in  the  arm  than 
in  the  chest.  I  have  witnessed  attacks  of  angina 
pectoris  where  the  pain  Avas  felt  in  one  case  in  the 
left  upper  arm,  and  in  the  other  in  the  left  lower 
arm.  In  both  cases  the  pain  started  in  the  chest  and 
radiated  to  the  arm,  and  the  patients  nursed  the  arm 
across  the  chest,  rocking  backwards  and  forwards  in 
agony.  In  other  cases  the  pain  has  been  equally 
severe  in  arm  and  in  chest,  and  on  careful  inquiry 
the  patients  could  find  no  difference  either  in  the 
character  or  severit}^  of  the  pain  in  the  two  places. 
Finally,  after  an  attack,  or  after  a  series  of  attacks, 
of  angina  pectoris  the  skin  and  subcutaneous  tissues 
in  the  region  of  the  chest  and  arm  where  the  pain 
was  felt  became  hyperalgesic,  and  it  is  reasonable  to 
conclude  that  there  is  a  direct  relation  between  the 
pain  and  the  hyperalgesia,  and  that  these  phenomena 
were  due  to  the  stimulation  of  the  same  nerves.  As 
these  nerves  are  the  cerebro-spinal  nerves  supplying 
the  chest  wall  and  the  arm,  the  pain  in  the  chest  has 
the  same  kind  of  origin  as  the  pain  in  the  arms,  i.e., 
the  pain  in  angina  pectoris  is  a  referred  pain. 

A  similar  series  of  phenomena  can  be 
seen  in  affections  of  other  organs,  where  the 
contiguous     nerve     centres     in     tlic     spinal     cord 


58  Chapter    V. 

supply  parts  widely  separated.  Thus,  in  renal  colic 
the  pain  is  described  as  being  felt  in  the  ureter,  then 
shooting  into  the  testicle.  On  page  46  I  point  out  the 
meaning  of  this  distribution  of  the  pain,  and  that 
observation  clearly  shows  the  mechanism  by  which 
the  pain  and  other  reflex  phenomena  are  produced. 

Another  argument  employed  to  indicate  that 
pain  may  be  felt  in  the  organ  is  that  the  pain  is  felt 
not  only  in  the  situation  where  it  is  known  that  the 
organ  is  situated,  but  that  it  is  felt  deeper  than 
the  skin.  Thus,  the  pain  in  angina  pectoris  is 
variously  described  as  being  under  the  breast-bone, 
and  some  physicians  describe  it  as  being  in  the  aorta, 
and  as  actually  travelling  along  the  arch  of  the 
aorta.  This  idea  also  seems  to  receive  support  when, 
in  addition,  some  agency  directly  affecting  the  organ 
seems  to  give  rise  to  the  pain,  as  in  gastric  ulcer  on 
taking  food  ;  or  in  the  case  of  pain  arising  from  the 
oesophagus  on  drinking  hot  fluids. 

Before  determining  the  nature  of  the  pain  in 
such  cases  it  is  necessary  to  realise  certain  peculiari- 
ties in  the  character  of  visceral  pain.  It  is  not 
possible  to  describe  visceral  pain  by  any  features 
peculiar  to  it,  for,  although  many  varieties  might 
be  described,  there  is  nothing  in  any  of  them  to  dis- 
tinguish them  from  the  pain  resulting  from  stimu- 
lation of  a  cerebro-spinal  nerve  itself,  either  in  its 
peripheral  distribution,  or  in  some  part  of  its  course 
in  the  trunk  of  the  nerve  or  in  the  central  nervous 
S3  stem.  It  is  for  this  reason  that  one  frequently 
finds  patients  suffering  from  pain  due  to  a  visceral 
lesion  treated  for  neuritis,  neuralgia,  rheumatism,  or 
some  affection  peculiar  to  a  cerebro-spinal  nerve.  In 
many  cases  of  visceral  pain,  though  the  suffering 


Visceral  Pain — continued.  59 

may  be  very  great,  the  pain  itself  is  of  so  vague  and 
ill-defined  a  character  that  its  exact  situation  is  not 
easily  ascertained  unless  attention  is  paid  to  this 
point  while  the  pain  is  actually  present.  Because  of 
this  vagueness  in  locality  it  is  sometimes  assumed 
that  this  vagueness  is  an  evidence  of  its  presence  in 
an  organ,  as  it  is  notorious  that  the  viscera  are  defi- 
cient in  the  nervous  mechanism  subserving  the  func- 
tion of  localisation.  This  interpretation  of  the  seat  of 
pain  would  seem  to  be  strengthened  by  the  fact  that 
patients  will  often  say  that  the  pain  is  felt  deeper 
than  the  skin,  as  if  it  were  in  their  insides.  If, 
however,  we  examine  those  patients  in  whom  the 
pain  is  found  to  radiate  some  distance  away  from 
the  offending  organ,  it  will  be  found  that  the  same 
kind  of  sensations — the  vagueness,  and  the  depth  of 
the  pain,  are  also  present  in  what  is  undoubtedly 
referred  pain.  It  is  in  cases  of  heart  pain  that 
this  can  also  best  be  studied.  It  frequently  happens 
that  the  patient  will  describe  the  region  in  which  the 
pain  is  felt  in  such  general  terms  that  no  clear  con- 
ception can  be  acquired  of  the  situation  of  his  pain. 
He  may  say  he  feels  it  in  his  arm,  but  be  uncertain 
in  which  arm  he  feels  it.  Or,  if  he  describes  it  as 
appearing  in  the  left  arm,  he  can  give  no  clear  idea 
of  the  particular  part  of  the  arm.  If,  however,  he  be 
interrogated  while  he  is  actually  suffering  from  the 
pain,  he  will  describe  with  accuracy  the  parts  in 
wliicli  the  pain  is  felt.  It  is  my  custom  in  these  cases 
to  ask  the  patient  to  note  accurately  the  situation  in 
which  the  pain  is  felt,  and  the  manner  in  which  it 
spreads,  in  the  next  examination  the  patient,  if  he 
has  suffered  in  the  meantime  from  a  recurrence  of  the 
pain,  can  usually  give  a  very  clear  account  of  the 


60  Chapter    V. 

pain  and  its  radiation,  and  will  indicate  with  pre- 
cision the  distribution  of  contiguous  nerves  in  the 
chest  and  arm,  as  shown  in  such  figures  as  Fig.  6, 
p.  95,  and  Fig.  18,  p.  238,  whereas  in  the  first 
account  no  such  definite  description  could  be 
obtained. 

The  situation  of  the  pain  in  regard  to  its  depth 
is  the  same  in  referred  pain  in  the  arm  as  in  the 
chest.  In  angina  pectoris  the  patient  will  describe 
his  pain  as  deep  in  the  arm  ;  "in  the  flesh  "  is  a 
description  not  infrequent.  If  in  such  cases  it  be 
asked  if  the  pain  here  differs  from  that  felt  in  the 
chest — differs,  that  is  to  say,  from  the  pain  supposed 
to  be  felt  "in  the  heart  " — the  answer  Avill  be  that 
they  are  identical  in  character,  the  only  difference 
being  that  sometimes  the  chest  pain  is  the  more 
severe,  and  in  other  cases  that  the  arm  pain  is  the 
more  severe.  This  peculiarity  in  the  sensation  of 
depth  of  pain,  or,  when  it  is  on  the  trunk,  the 
attributing  of  pain  to  some  internal  organ,  is  seen 
also  in  such  a  characteristic  affection  of  the  cerebro- 
spinal nerves  as  herpes  zoster.  It  has  been  estab- 
lished b}^  Head  and  Campbell  that  this  complaint  is 
due  to  an  inflammation  of  the  ganglia  of  the  root  of 
the  posterior  spinal  nerves.  In  places  where  no 
eruption  appears,  or  long  after  the  eruption  has 
healed,  pains  of  a  most  excruciating  character  may 
be  experienced.  In  their  description  of  these  pains 
the  patients  will  state  that  they  feel  deep  in  the 
belly,  and  not  infrequently  the  patient  attributes 
these  to  his  bowels  and  consults  his  doctor  lest  a 
cancer  or  some  other  painful  disease  has  affected  his 
bowels.  These  pains  of  herpes  zoster  are  also  often 
somewhat    vague    and    difficult    to    localise    with 


Visceral  Pain — continued.  61 

precision,  though  they  are  always  felt  within  an  area 
of  definite  hmits.  The  same  features  are  present 
when  the  pain  due  to  herpes  is  in  the  arm,  and  in 
one  case  the  pain  occurred  in  paroxysms  so  hke  an 
attack  of  angina  pectoris  that  at  first  I  felt  inclined 
to  attribute  the  pain  to  an  attack  of  that  affection. 
The  appearance  of  a  herpetic  eruption  on  the  chest 
and  arm  revealed  the  true  cause  (compare  the 
shaded  areas  in  Fig.  6,  p.  95,  and  Fig.  7,  p.  97).  This 
feeling  of  pain  deep  in  the  body  is,  therefore,  no 
reason  for  assuming  the  pain  to  be  in  the  organ. 
The  pain  resulting  from  drinking  hot  fluids,  due  in 
all  likelihood  to  stimulation  of  the  oesophagus, 
cannot  be  felt  in  the  oesophagus.  The  pain  itself  is 
felt  so  distinctly  in  the  middle  line  of  the  front  of 
the  chest,  while  the  oesophagus  does  not  lie  alto- 
gether in  the  middle  line.  Furthermore,  the 
oesophagus  is  situated  actually  nearer  the  skin  of  the 
back,  yet  the  pain  is  never,  or  rarely,  felt  in  this 
position.  It  seems  more  reasonable  that  the 
oesophageal  pain  follows  the  laws  that  regulate  the 
mechanism  of  pain  in  the  other  portions  of  the 
digestive  tube  as  described  in  Chapter  XII.  {see  also 
Fig.  8.,  p.  117). 

Another  explanation  for  the  pain  being  felt  at 
a  distance  from  the  offending  organ  is  sometimes 
put  forward  when  it  is  said  that  the  individual 
refers  the  pain  to  the  place  usually  occupied  by  the 
viscera,  according  to  a  law  of  "  average  localisation." 
This  so-called  law  is  a  pure  assumption  and  neglects 
or  ignores  the  essential  facts,  and  is  indeed  merely 
a  means  to  avoid  a  difficulty.  When  cases  of 
"average  localisation"  are  carefully  examined,  other 
phenomena  may  be  found,  which  shed  light  upon  the 


62  Chapter    V. 

distribution  of  the  pain.  When  no  evidence  can  be 
found  to  explain  satisfactorily  the  region  in  which 
pain  is  felt,  it  is  far  better  to  acknowledge  our 
ignorance  and  strive  to  remedy  it,  than  to  stultify 
one's  position  by  giving  some  plausible  explanation 
incapable  of  proof. 


(     63     ) 


Chapter  Vl. 

INCREASED    SENSIBILITY    OF    THE 
EXTERNAL    BODY    WALL. 

"29.  Hyperalgesia. 

30.  Cutaneous   Hyperalgesia. 

31.  Muscular   Hyperalgesia. 

32.  Hyperalgesia  of   Other  Structures. 

33.  Effect  of  Exercise  on   Hyperalgesic  Muscles. 
34  The   Areas  of  Cutaneous   Hyperalgesia. 

35.  The   Areas  of  Muscular   Hyperalgesia. 

36.  Tender  Vertebrce. 

29.  Hyperalgesia. — In  the  older  writings  ten- 
■derness  of  the  tissues  in  visceral  disease  sometimes 
receives  a  passing  reference.  Morgagni  mentions 
it,  and  John  Hunter,  after  an  attack  of  angina  pec- 
toris, speaks  of  his  left  arm  being  very  sore,  so  that 
he  could  not  bear  it  to  be  touched.  In  1891,  a 
patient  I  had  been  attending  for  an  attack  of  gall- 
stone colic  called  upon  me,  and  as  he  entered  my 
room  I  observed  he  was  holding  his  right  arm  stiffly 
away  from  his  side.  On  inquiring  why  he  did  this, 
he  told  me  that  the  skin  was  so  tender  he  could  not 
bear  the  slightest  pressure.  On  stripping  him,  I 
found  a  large  field  of  skin  extremely  tender  to  touch, 
covering  the  upper  part  of  the  abdomen  and  lower 
part  of  the  chest  wall  on  the  right  side.  This  caused 
me  to  look  for  cutaneous  tenderness  in  other  cases, 
and  I  found  it  fairly  frequentty,  and  I  published  an 
account  of  these  observations  in  1892,  when  I  called 


64  Chapter    VI. 

attention  to  the  fact  that  there  was  a  distinct 
relationship  between  the  viscera  and  certain  defined 
areas  of  skin.  This  method  of  examination  was  also 
taken  up  by  Head,  who  had  previously  been  making 
researches  on  the  origin  of  pain  in  visceral  disease, 
and  he  mapped  out  the  areas  of  cutaneous  hyperal- 
gesia in  visceral  disease  that  corresponded  to  the 
areas  of  eruption  in  herpes  zoster.  I  pursued  the 
subject  further,  and  found  that  not  only  did  the 
surface  of  the  skin  become  occasionally  hyperalgesic, 
but  the  deeper  layers  and  the  muscles  also,  while 
glands,  like  the  mammae  and  testicles,  become  also 
very  tender.  This  tenderness  of  the  muscles  wa& 
invariably  coupled  with  an  extremely  sensitive  and 
powerful  reflex  contraction,  so  that  on  the  lightest 
palpation  they  often  became  violently  contracted. 
In  addition,  the  muscles  sometimes  became  con- 
tinuously contracted  for  long  periods.  As  these 
muscular  phenomena  are  of  considerable  importance, 
I  shall  deal  with  them  in  the  next  chapter. 

30.  Cutaneous  Hyperalgesia.  —  Cutaneous 
hyperalgesia  due  to  visceral  disease  exists  in  two 
forms,  superficial  and  deep.  The  former  is  recog- 
nised by  an  extreme  sensitiveness  of  the  skin  when 
lightly  stroked  by  a  pin  head,  or  by  moving  hairs, 
and  the  latter  when  pressure  between  finger  and 
thumb  is  made  to  the  whole  thickness  of  the  skin. 
The  superficial  form  is  comparatively  rare,  and  the 
deeper  form  is  always  present  with  it.  The  area  in 
which  the  superficial  occurs  is  less  than,  and  included 
within,  the  deeper.  The  borders  are  in  both  cases 
ill-defined  and  inconstant  ;  at  one  moment  the 
patient  will  say  the  skin  is  tender,  and  on  returning 
to  this  part  a  few  minutes  after,  the  patient  may 


Increased  Sensibility  of  the  External  Body  Wall.    65 

not  feel  it  tender.  The  result  is  that  the  liyperal- 
gesic  area  is  ill-defined,  and  I  have  been  unable  to 
verify  any  exact  limitation  of  fields  such  as  Head 
describes. 

31.  Muscular  Hyperalgesia. — Hyperalgesia  of 
the  muscles  is  far  more  common  than  hyperalgesia 
of  the  skin,  but  can  only  be  recognised  with  cer- 
tainty when  the  skin  sensibility  is  unaltered,  as 
hyperalgesia  cannot  be  accurate^  recognised  in 
deeper  structures  if  the  skin  covering  them  is 
tender.  Before  testing  for  deeper  hyperalgesia  the 
condition  of  the  cutaneous  sensibility  should  first  be 
ascertained. 

The  same  method — grasping  between  the  finger 
and  thumb— is  the  best  also  for  eliciting  the 
hyperalgesia  of  such  structures  as  the  muscles.  Many 
of  the  muscles,  as  the  sterno-mastoid,  upper  border 
of  the  trapezius,  pectoralis  major,  erector  spinse,  can 
be  grasped,  and  the  sensibility  compared  with  the 
corresponding  muscles  of  the  opposite  side.  It  is 
not  easy  to  do  this  always  with  the  flat  muscles  of 
the  abdominal  wall,  particularly  when  they  are  con- 
tracted. By  such  devices  as  pushing  the  finger  into 
the  umbilicus  the  recti  can  be  hooked  up  and  com- 
pressed. By  light  pressure  on  the  contracted  muscles 
one  can  feel  fairly  certain  of  the  hyperalgesic  struc- 
tures. Sometimes,  to  decide  the  matter,  pressure  has 
to  be  applied  to  the  origin  of  the  muscles  at  the  ribs, 
when,  with  a  little  dexterity,  the  pressure  can  be 
exercised  on  the  muscle  against  the  ribs.  These 
devices  have  to  be  resorted  to  when  the  muscles  over- 
lying a  diseased  organ  are  tender,  as  otherwise  the 
pain  is  often  referred  to  the  organ.  As  a  rule  the 
tissues   that   are   painful   can    be   differentiated   by 


66  Chapter    VI. 

observing  that  the  hyperalgesic  area  extends  beyond 
the  organ.  Thus,  in  enlargement  of  the  hver  ten- 
derness over  the  organ  may  be  fomid,  but  it  may  be 
difficult  to  tell  whether  the  pain  is  in  the  organ  or 
external  body  wall.  On  mapping  out  the  size  of  the 
organ  and  the  area  of  hyperalgesia,  it  will  be  found 
that  they  do  not  correspond. 

32.  Hyperalgesia  of  Other  Structures  (extra 
peritoneal  tissue,  mammae,  testicle). — I  have  referred 
to  the  layer  of  tissue  outside  the  peritoneum  in  which 
numerous  fine  nerve  fibrils  ramify.  I  am  inclined  to 
think  that  this  part  can  become  very  tender,  as  I  have 
found  pain  complained  of  when  pressure  was  made 
between  the  recti.  It  is  very  difficult,  however,  to 
distinguish  the  tenderness  of  this  tissue  from  that 
of  the  skin  and  muscles.  Glands,  such  as  the 
mammae  and  the  testicles,  may  be  very  tender  on 
pressure.  This  can  be  shown  by  gentle  pressure,  first 
making  sure  that  there  is  no  cutaneous  hyperalgesia. 
The  reason  for  the  pain  on  pressing  the  testicle  is 
explained  on  p.  36. 

33.  Effect  of  Exercise  on  Hyperalgesic 
Muscles. — The  exercise  of  muscles  affected  with 
this  hyperalgesia  usually  results  in  increasing  the 
hyperalgesia,  inducing  pain  and  contraction  of  the 
muscles.  The  hard,  tender  belly,  and  "  dragging  " 
pains  found  in  various  visceral  affections,  as  gall- 
stones, renal  calculus,  appendicitis,  are  always  asso- 
ciated with,  if  not  due  to,  this  muscular  hyperalgesia. 
In  such  cases  walking  induces  pain,  and  the  contrac- 
tion of  the  muscles  may  compel  the  patient  to  stoop. 

After  exercising  the  muscle,  or  after  the  testing 
for  muscular  hj^peralgesia,  the  patient  may  suffer 
from  aching  in  the  muscles  which  may  last  for  hours. 


Increased  Sensibility  of  the  External  Body  Wall.    67 

34.  The    Areas    of    Cutaneous    Hyperalgesia. — 

Sherrington  has  demonstrated  that  the  spinal  nerves, 
after  they  leave  the  spinal  cord,  are  distributed  to 
the  skin  in  fairly  definite  areas  around  the  body. 
Somewhat  similar  areas  are  found  in  herpes  zoster, 
which  Head  and  Campbell  have  shown  to  be  due  to 
destructive  inflammation  of  the  ganglia  of  the  pos- 
terior nerve  roots.  These  areas  are  spoken  of  as 
"  segments,"  and  the  spinal  cord  is  supposed  to  be 
"  segmentally  "  arranged.  The  question  arises,  is 
the  hyperalgesia  of  \4sceral  disease  segmental  in  its 
distribution  ?  If  by  this  is  meant  that  when  hyperal- 
gesia appears  it  first  extends  to  the  whole  of  one 
segment  before  affecting  the  next,  the  answer  is  in 
the  negative.  When  hyperalgesia  appears  it  extends 
very  definitely  along  portions  of  neighbouring  nerve 
areas,  and  from  my  observation  is  never  limited  to 
the  full  extent  of  one  "  segment."  The  spread  is  from 
one  definite  portion  of  a  nerve  area  to  another,  with- 
out completely  affecting  the  whole  of  one  "  segmen- 
tal "  area.  In  widespread  hyperalgesia  the  whole  of 
a  series  of  nerve  areas  may  be  affected,  as  when  one 
half  of  the  trunk  is  hA^peralgesic.  The  manner  of 
spread  is  well  seen  in  certain  cases  of  angina  pec- 
toris, when  it  may  begin  in  a  patch  affecting  portions 
of  the  distribution  of  the  third  and  fourth  thoracic 
nerves,  and  extend  into  the  arms  affecting  portions 
of  the  second  and  first  thoracic  nerve  areas. 
Although  appearing  in  tlie  region  of  distribution  of 
four  nerves  the  hyperalgesia  does  not  affect  the 
whole  of  the  distribution  of  any  one.  Cutaneous 
hyperalgesia  will  usually  be  found  in  an  ill-defined 
patch  occupying  portions  of  the  fiekl  of  distribution 
of  one  or  more  spinal  nerve  roots.     The  centres  of 


68  Chapter    VI. 

these  nerves  in  the  cord  will  be  found  to  be  in  close 
association  with  the  sympathetic  nerves  from  the 
offending   viscus. 

35.  The  Areas  of  Muscular  Hyperalgesia. — 
There  is  great  difficult^'  in  delimiting  the  areas  of 
muscular  hyperalgesia,  as  frequently  only  portions  of 
the  muscle  are  demonstrably  hyper  algesic.  In  such 
muscles  certain  spots  may  be  more  tender  than  the 
rest.  Here  a  small  nerve- trunk  may  be  pressed  upon, 
and  this  nerve  may  be  distributed  to  other  tissues 
than  the  muscle  (as  in  McBurney's  point).  I  am 
disposed  to  consider  that  the  sensory  nerve  supply 
of  a  muscle  is  from  the  same  region  of  the  cord  as 
the  motor.  As  the  motor  supply  is  more  accurately 
known  than  the  sensory,  we  may  by  this  means  more 
accurately  ascertain  the  centre  of  stimulation  in  the 
cord. 

It  has  been  long  known  that  the  muscles  have 
an  afferent  nerve  supply  reaching  the  cord  by  the 
anterior  nerve  roots  with  the  motor  nerves.  Head 
describes  a  form  of  pain  elicited  by  compressing 
muscles  which  is  conveyed  by  these  nerves. 
Whether  these  are  the  nerves  that  show  tenderness 
in  muscular  hyperalgesia  I  cannot  say,  but,  if  so, 
their  centres  in  the  spinal  cord  must  be  in  close 
proximity  to  the  nerve  that  conducts  pain  from  the 
skin. 

36.  Tender  Vertebrae. — In  many  cases  of  vis- 
ceral disease  pressure  over  the  spines  of  certain 
vertebrae  elicits  pain,  sometimes  of  a  very  acute 
character.  I  have  not  been  able  to  account  satis- 
factorily for  the  manner  in  which  this  arises.  These 
■  tender  vertebrae  are  usually  associated  with  areas  of 
hyperalgesia   in   the    skin    and   muscles    of    certain 


Increased  Sensibility  of  the  External  Body  Wall.    69 


Fig.  2. 

Areas  in  which  pain  is  sometimea  felt  in  affections  of  heart  (a)  ;  of 
tho  stomach  (b)  ;  of  the  liver  (c)  ;  of  the  rectum  and  uterus  (n).  The 
numbers  refer  to  the  dorsal  vertebrae,  and  those  included  in  each  area  are 
sometimes  tender  in  diseases  of  the  organ  to  whic^h  the  letters  refer. 


70  Chapter    VI. 

definite  areas,  at  some  distance  from  the  spinal 
column.  Such  hyperalgesic  areas  are  supplied  by 
the  nerves  that  issue  from  the  cord  at  the  level  of 
the  tender  vertebrae.  The  skin  over  the  vertebrae 
may  not  be  hyperalgesic,  so  that  the  pain  is  elicited 
from  deeper  structures.  The  pain  is  referred  to  the 
region  of  the  vertebrae  that  are  tender.  These  tender 
vertebrae  must  not  be  confused  with  the  spinal  ten- 
derness so  common  in  certain  neurotic  cases.  In 
these  latter  the  tenderness  is  not  limited  to  a  few 
vertebrae,  but  the  whole  spine  is  tender  on  pressure. 
In  1892  I  gave  a  figure  showing  the  vertebrae  that  I 
found  tender  in  association  with  lesions  of  certain 
organs,  and  continued  observation  has  confirmed  the 
opinion  there  expressed.  The  vertebrae  that  are 
tender  in  association  with  the  different  organs  are 
shown  in  Fig.  2. 

If  the  visceral  origin  of  the  tenderness  of  these 
vertebrae  be  not  kept  in  view,  an  error  in  diagnosis 
may  result  from  the  fact  that  the  tender  vertebrae 
may  be  looked  upon  as  evidence  of  disease  of  the 
spinal  colum.n.  This  is  all  the  m,ore  likely  to  be  the 
case  if  there  is  well-marked  evidence  of  cutaneous 
hyperalgesia.  I  have  seen  a  patient  encased  in  a 
plaster  of  Paris  jacket  on  the  recommendation  of 
a  distinguished  neurologist,  because  of  an  extreme 
tenderness  of  the  sixth  and  seventh  dorsal  vertebrae, 
and  a  band  of  marked  hyperalgesia  of  the  skin 
around  the  left  half  of  the  upper  part  of  the 
abdomen.  At  the  post-mortem  examination  no 
disease  of  the  spinal  column  could  be  detected,  but 
there  was  a  cancer  at  the  cardiac  end  of  the  stomach. 


(     71     ) 


Chapter  yil 

THE    VISCERO-MOTOR    REFLEX. 


37.  Definition. 

38.  Effects  of  Stimulation  of  Motor  Nerves  on  Limb 

Muscles  and  on  Flat   Abdominal  Muscles. 

39.  Character  of   the     V iscero-motor    Contraction. 

40.  Conditions  Causing  the  V iscero-motor  Reflex. 

41.  Experimental  Production  of  the    V iscero-motor. 

Reflex. 

37.  Definition.  —  By  the  term  viscero-motor 
reflex  I  mean  the  contraction  of  voluntary  muscles  in 
the  external  body  wall  in  response  to  a  stimulus 
arisin^^  from  a  viscus,  as  distinct  from  the  normal 
superficial  reflex  where  the  muscle  gives  a  brief  con- 
traction in  response  to  a  stimulus  from  the  skin  (as 
the  plantar  reflex).  Everyone  is  familiar  with  the 
viscero-motor  reflex,  wliicli  is  best  seen  in  the  board- 
like hardness  of  the  abdominal  wall  in  certain  vis- 
ceral diseases.  A  similar  reflex  is  found  in  the 
muscles  of  a  hmb  when  an  adequate  stinxulus  arises 
from  an  inflamed  joint.  A  shoulder  joint  may  be 
absolutely  immobile  on  account  of  the  stronij;  tonic 
contractions   of   the   surrounding   muscles.       if   tlu' 


72  Chapter    VII. 

patient  is  put  deeply  under  chloroform  the  muscles 
relax,  and  the  joint  can  be  freely  moved,  and  while 
being  moved  a  grating  may  be  detected.  As  the 
patient  recovers  from  the  general  anaesthetic,  the 
muscles  again  become  firmly  contracted  and  fix  the 
joint. 

38.  Effects  of  the  Stimulation  of  Motor 
Nerves  on  Limb  Muscles  and  on  Abdominal 
Muscles. — It  is  in  the  muscles  forming  the  abdo- 
minal wall  that  this  reflex  can  best  be  studied.  Some 
years  ago  I  pointed  out  that  these  muscles  could  be 
demonstrated  to  possess  the  power  of  contracting  in 
small  sections  in  response  to  visceral  stimulation. 
Later  I  found  that  Sherrington  had  described  a 
difference  in  the  reaction  to  nerve  stimulation 
between  these  flat  muscles  and  the  muscles  of  the 
limbs.  The  fibres  that  constitute  the  nerve  supply 
of  any  given  muscle  leave  the  spinal  cord  in  separate 
bundles.  If  one  of  these  bundles  be  stimulated  the 
whole  length  of  a  limb  muscle  like  the  sartorius  will 
contract.  On  the  other  hand,  if  one  of  the  bundles 
that  constitute  the  nerve  supply  of  one  of  the 
abdominal  muscles  be  stimulated,  only  a  portion  of 
the  fibres  of  the  muscle  will  contract. 

The  contraction  of  a  small  portion  of  the 
abdominal  muscle,  in  response  to  a  visceral  stimulus, 
may  remain  for  an  indefinite  period.  The  limited 
hardness  thus  arising  gives  to  the  palpating  hand 
the  impression  of  an  underlying  tumour,  and  not 
only  does  it  give  the  impression,  but  it  is  often 
mistaken  for  a  tumour.  I  have,  on  several  occasions, 
seen  experienced  surgeons  and  physicians  make  this 
mistake,  and  at  the  subsequent  operation  no  tumour 
was  found.   This  hard  contracted  portion  of  a  muscle 


The    Viscero-motor  Reflex.  73 

is  often  h\'peralgesic,  and  its  tenderness  is  readily 
mistaken  for  an  evidence  of  tlie  sensitiveness  of  the 
supposed  "  abdominal  tumour." 

The  extent  of  this  contraction  of  the  abdominal 
muscle  is  variable.  In  appendicitis  it  may  be  limited 
to  a  few  strands  of  muscle,  which  may  be  mistaken 
for  the  appendix  itself.  It  may  be  more  extensive 
and  resemble  a  rounded  tumour,  and  this,  in  appen- 
dicitis, is  often  mistaken  for  swelling  in  and  around 
an  appendix  (the  perityphlitis  of  olden  days).  On 
the  other  hand,  the  whole  of  the  right  side  of  the 
abdomen,  and  even  a  portion  of  the  left,  may  be 
found  hard  and  board-like. 

39.  The  Character  of  the  Viscero-motor  Con- 
traction.— There  are  features  in  these  contracted 
muscles  that  have  not  been  appreciated,  and  which 
open  up  some  new  points  in  the  physiology  of  con- 
tracted muscle.  As  a  rule  the  contraction  is  long 
continued,  lasting,  it  may  be,  for  daj^s  or  weeks — or  it 
may  be  months — as  long  as  the  visceral  lesion  keeps 
up  an  adequate  stimulus.  As  a  rule  it  begins  as  a 
slight  increase  in  the  tonicity  of  the  muscles,  and 
is  detected  through  one  side  of  the  abdomen  or  one 
portion  of  a  muscle  being  a  little  more  resistant  than 
other  parts.  At  this  stage  it  is  readily  provoked  to  a 
strong  and  firm  contraction  by  palpation.  If,  as 
often  happens,  the  skin  or  the  muscle  itself  is 
hj'peralgesic  its  reflex  contraction  is  very  readily 
induced,  but  after  the  contraction  it  remains  for  a 
time  strongly  contracted.  Thus,  in  palpating  the 
epigastrium  in  cases  of  gastric  ulcer,  if  the  part  is 
not  explored  with  gentleness  the  muscles  imme- 
diately become  contracted,  and  remain  strongly 
•contracted.        On   the   other   hand,    if   very   gently 


74  Chapter    VII. 

palpated,  all  that  can  be  detected  is  a  resistance 
slightly  greater  than  normal,  and  with  the  slightest 
increase  of  pressure  an  increase  in  the  hardness  of 
the  muscle  is  produced. 

When  this  contracted  muscle  is  examined  under 
chloroform  certain  characteristic  features  are  found. 
It  is,  as  a  rule,  the  last  portion  of  the  muscular 
system  to  yield  to  the  influence  of  the  anaesthetic, 
remaining  hard  and  contracted  when  all  the  other 
muscles  are  limp  and  flaccid.  The  chloroform  has 
often  to  be  pushed,  and  even  in  deep  anaesthesia  no 
relaxation  may  take  place.  I  have  sometimes 
observed  that  the  muscles  yield  after  an  attack  of 
sickness.  In  many  cases  the  contraction  persists, 
however  deep  the  anaesthesia,  and  however  long  it 
may  be  pushed.  In  such  instances,  when  the  muscle 
is  cut  during  an  operation  the  fibres  remain  stiff  and 
unyielding,  and  one  is  much  hampered  in  forcing  an 
opening  through  the  cut  muscle.  Thus,  in  one  case 
of  appendicitis  the  muscle  was  rigid  and  hard,  and 
gave  the  impression  of  an  underh' ing  tumour.  When 
cut  the  fibres  would  not  yield,  and  I  had  much 
difficulty  in  getting  my  finger  in  to  explore  the 
abdomen.  There  was  no  underlying  tumour,  and 
the  peritoneum  and  bowel  in  the  neighbourhood 
were  perfectly  healthy.  Deep  down  an  inflamed  and 
suppurating  appendix  was  found. 

The  contraction  may  come  on  suddenly  with  the 
sudden  onset  of  some  visceral  trouble.  Thus,  in  a 
case  of  renal  calculus,  cited  on  page  44,  the  onset  of 
pain  was  immediately  succeeded  by  the  contraction 
of  the  abdominal  muscles,  and  the  patient  was  also 
conscious  of  the  contraction  of  the  cremaster  muscle 
by  the  pulling  up  of  the  testicle.    In  angina  pectoris 


The   Viscero- motor  Reflex.  75 

the  sudden  onset  of  the  powerful  contraction  of  the 
intercostal  muscles  is  recognised  by  the  feeling  of 
compression  of  the  chest,  which  is  so  great  at  times 
that  the  patient  states  that  he  feels  as  if  his  breast- 
bone would  break. 

40.  Conditions  Causing  the  Viscero -motor 
Reflex. — There  are  many  conditions  which  produce 
this  reflex.  Peritonitis  causes  it,  and  as  the  muscle 
is  usually  also  tender,  these  symptoms  of  hardness 
and  tenderness  of  the  abdominal  wall  have  come  to 
be  looked  upon  as  undoubted  evidence  of  peritonitis. 
But  these  symptoms  ma}^  be,  and  often  are,  present 
with  absolutely  no  peritonitis.  Thus,  I  have  found 
tenderness  with  firm  contraction  of  the  lower  part  of 
the  left  rectus  abdominis  muscle  in  a  case  of  stone 
in  the  bladder  without  peritonitis.  Hardness  and 
tenderness  of  the  recti  over  the  epigastrium  is  com- 
mon in  gastric  ulcer,  and  I  have  found  these  symp- 
toms without  any  peritonitis.  I  have  also  found 
hardness  over  a  limited  area  in  the  left  lumbar 
region  due  to  a  tuberculous  ulcer  in  the  posterior 
wall  of  the  descending  colon,  and  there  was  no  peri- 
tonitis underlying  the  hard  and  tender  muscle.  In 
like  manner  widespread  tenderness  of  the  abdominal 
wall  witli  hard  contraction  of  the  whole  abdominal 
muscles  may  occur  without  any  peritonitis.  As 
illustrating  the  extensive  muscular  contraction  due 
to  visceral  stimulation  I  cite  the  following  case  :  I 
was  summoned  to  operate  upon  a  fellow  practitioner 
for  obstruction  of  the  bowels.  The  symptoms  were, 
no  movement  of  the  bowels  for  two  days,  nor  had 
any  flatus  been  passed  ;  some  vomiting,  but  not 
faecal  ;  considerable  abdominal  distension,  with  gi*eat 
hardness  of  the  whole  abdominal  wall,  and  pain  on 


76  Chapter    VII. 

the  slightest  pressure.  Some  difficulty  was  experi- 
enced in  passing  the  finger  into  the  bowel  on  account 
of  the  strong  contraction  of  the  sphincters.  The 
patient  had  severe  attacks  of  pain  every  few 
moments.  The  pain  began  in  the  left  lumbar  region, 
passing  forwards  and  downwards  towards  the  pubes. 
Pain  was  felt  on  light  pressure  on  the  left  testicle. 
From  the  situation  of  the  pain,  and  the  tenderness 
on  pressing  the  left  testicle,  I  had  no  hesitation  in 
recognising  the  condition  as  one  of  renal  calculus. 
In  my  experience  the  pain  in  obstruction  of  the 
bowel  is  never  so  distinctly  one-sided.  The  inability 
to  have  the  bowels  moved  was  simply  due  to  the 
violent  contraction  of  the  sphincters,  such  contrac- 
tion, with  the  contraction  of  the  abdominal  muscles, 
being  due  to  the  renal  calculus.  The  diagnosis  was 
confirmed  by  the  passage  of  a  calculus  next  day  with 
immediate  disappearance  of  all  the  symptoms.  This 
patient  had  two  subsequent  attacks  with  a  repe- 
tition of  all  the  foregoing  symptoms.  The  contraction 
of  the  muscles  was  undoubtedly  due  to  a  violent 
stimulation  passing  from  the  affected  organ  to  the 
spinal  cord.  There  the  irritation  spread,  affecting 
not  only  the  centres  of  the  sensory  nerves,  but  also 
the  centres  of  the  motor  nerves.  These  stimulated 
gave  rise  to  violent  muscular  contractions — the 
viscero-motor  reflex. 

41.  Experimental  Production  of  the  Viscero- 
motor Reflex. — Professor  Sherrington  has  recently 
been  making  an  investigation  into  the  effects  pro- 
duced in  the  abdominal  muscles  by  stimulating  the 
sympathetic  nerves.  He  dissects  out  and  divides  a 
branch  of  the  solar  plexus  going  to  the  bowel,  and 
stimulates  the  central  end.     There  is  an  immediate 


The   Viscero-motor  Reflex.  77 

response  in  the  broad  muscles  of  the  abdomen,  which 
contract  over  an  extensive  area.  By  dividing  one 
after  another  the  anterior  roots  of  those  spinal 
nerves  that  supph^  this  extensive  area,  the  extent  of 
the  contraction  becomes  greatly  limited  until  when 
there  is  but  one  posterior  root  left  intact  the  contrac- 
tion becomes  limited  to  a  few  fibres  of  the  muscle. 

This  investigation  is  not  yet  completed. 
Professor  Sherrington  having  given  me  this  verbal 
description  ;  but  it  is  not  necessary  here  to  insist 
further  upon  the  matter  than  to  point  out  that 
the  recognition  of  the  visceral  nerve  that  is  capable 
of  producing  a  given  contraction  of  a  limited  portion 
of  the  muscle  will  prove  an  invaluable  aid  in 
diagnosis. 


(     78     ) 


CHAPTER     VJII. 
ORGANIC    REFLEXES. 

42.  Vomiting. 

43.  Dyspnoea. 

44.  Secretory  Reflexes. 

45.  Cardiac  Reflexes. 

46.  Vaso-motor  and  Pilo-motor  Reflexes. 

There  are  a  number  of  reflex  acts,  apart  from 
the  viscero-sensory  and  viscero-motor  reflexes,  pro- 
duced by  the  stimulation  of  centres  in  the  spinal 
cord  and  medulla  from  a  viscus.  These  acts  may  be 
very  complicated,  bringing  into  play  a  large  number 
of  subsidiary  centres  as  in  the  reflex  act  of  vomiting, 
or  they  may  result  in  the  stimulation  of  some  gland 
as  the  salivary  glands  or  the  kidney.  JMan}^  of  these 
reflex  acts  are  obscure,  as  the  vaso-motor,  and  there 
are  probably  others  we  have  not  3'et  attained  tlie 
means  of  detecting. 

42.  Vomiting. — Vomiting  is  due  to  the  stimula- 
tion of  a  centre  in  the  medulla,  and  this  may  be 
plaj^ed  upon  from  a  great  many  sources,  as  from 
irritation  of  the  stomach,  from  disturbances  in  the 
brain,  impressions  made  on  the  senses  of  smell  and 
sight.  It  is  frequently  set  up  reflexly  from  stimula- 
tion of  the  viscera  of  the  abdominal  cavity  as  in 
affections  of  the  liver  or  bile  ducts,  kidnej^,  ureter. 


Organic  Reflexes.  79 

uterus,  ovaries,  testicles.  Its  occurrence  with  con- 
traction of  non-striped  muscle  is  a  curious  feature. 
In  labour  an  attack  of  vomiting  may  be  induced  at 
the  same  time  as  a  uterine  contraction.  Colic  due  to 
renal  calculus  and  gall-stone — the  pain  arising  from 
contraction  of  the  ureter  or  gall  duct  —  is  often 
accompanied  with  vomiting.  This  association  of 
vomiting  with  the  contraction  of  hollow  muscles,  so 
common  in  abdominal  organs,  never  occurs  in  affec- 
tions of  the  heart  or  lungs,  nor  in  affections  liniited 
to  the  bladder  or  rectum.  I  do  not  remember  ever 
seeing  vomiting  arise  as  a  reflex  in  heart  affections, 
nor  for  that  matter  from  a  lung  affection.  One  may 
get  vomiting  from  the  stress  of  coughing,  as  in 
phthisis  or  whooping  cough,  but  it  is  doubtful  if  it 
arises  as  a  reflex  from  stimulation  of  the  lungs  or 
pleura.  In  acute  febrile  conditions  vomiting  may 
arise,  as  in  kidney  disease,  from  some  general 
poisoning  effect. 

43.  Dyspnoea.  —  The  centre  for  respiration  is 
also  in  the  medulla,  quite  close  to  the  vomiting 
centre.  Dyspnoea  may  arise  directly  from  the  pre- 
vention of  the  entrance  of  air  into  the  lungs,  or 
because  the  blood  does  not  take  up  a  sufficient  amount 
of  oxygen.  It  may  be  excited  reflexly  also,  as  seen 
on  the  application  of  a  peripheral  stimulus  (immer- 
sion in  cold  water  causing  a  deep  inspiration).  In 
affections  of  the  lung,  as  pneumonia,  pulmonary 
apoplexy  or  infarcts,  intense  dyspnoea  may  arise,  far 
greater  than  the  mere  occlusion  of  the  air  cells 
would  account  for,  and  it  is  generally  assumed  that 
this  breath lessness  is  due  to  a  reflex  stimulation  of 
the  respiratory  centre.  Thus  I  have  seen  a  patient 
seized   with   an   attack   of  pulmonary   apoplexy   of 


80  Chapter    VIII. 

small  extent,  and  breathlessness  of  great  severity 
supervene.  After  lasting  a  few  hours  the  dyspnoea 
would  suddenly  cease,  and  the  patient  breathe  com- 
fortably. Some  forms  of  asthma  are  undoubtedly 
reflex.  Dyspnoea  may  arise  in  heart  affections  as  a 
pure  reflex,  altogether  apart  from  the  amount  of 
blood  that  is  supplied  to  the  lungs.  This  is  best  seen 
in  cardiac  asthma,  and  can  be  demonstrated  in  some 
cases  where  there  is  enlargement  of  the  liver.  Gentle 
pressure  on  the  liver  with  both  hands  will  fill  the 
right  heart  and  distend  the  veins  in  the  neck,  and 
the  patient  will  at  once  experience  a  feeling  of 
dyspnoea.  The  sense  of  breathlessness  is  of  great 
importance  in  the  examination  of  cases  of  heart 
failure. 

The  possibility  of  a  reflex  spasm  of  the  bronchial 
muscles  should  be  kept  in  mind,  in  view  of  the  fact 
that  all  non-striped  muscles  are  liable  to  be  played 
upon,  and  a  prolonged  contraction  produced. 

44.  Secretory  Reflexes. — When  the  stimulus 
from  a  viscus  reaches  a  part  of  the  spinal  cord  where 
arise  nerves  supplying  glands,  increased  flow  of 
secretion  occurs.  This  is  best  seen  in  the  kidney  and 
salivary  glands.  In  a  number  of  cases  of  angina 
pectoris  the  pain  may  extend  to  the  jaws,  and  the 
saliva  may  dribble  from  the  mouth.  A  similar  reflex 
affects  the  kidney.  Some  individuals,  after  an  attack 
of  severe  pain,  as  angina  pectoris  or  headache,  or 
after  some  stimulation  of  an  organ,  such  as  paroxys- 
mal tachycardia  or  mental  excitement,  have  a  desire 
to  micturate  and  pass  a  large  quantity  of  pale  urine 
of  low  specific  gravity.  These  two  reflexes  are  due 
to  stimulation  of  centres  in  the  medulla.  Wherever 
the  nerve  centres  supplying  separate  organs  are  in 


Organic   Reflexes.  81 

close  approximation,  the  stimulation  of  one  viscus 
may  affect  another.  In  many  cases  of  sub-acute 
appendicitis,  for  instance,  there  is  frequent  micturi- 
tion though  the  appendix  may  be  situated  at  some 
distance  from  the  bladder. 

From  the  consideration  of  these  organic  reflexes 
it  is  clear  that  there  must  be  some  special  connection 
from  such  remote  organs  as  the  testicle  and  ureter 
(severe  vomiting  ma}^  occur  in  orchitis  and  in  renal 
colic)  and  the  niedullary  centres,  probably  b}^  some 
special  path  in  the  spinal  cord.  In  certain  cases  the 
stimulus  m.ay  reach  the  medulla  by  the  afferent  fibres 
of  the  vagus. 

45.  Cardiac  Reflexes. -Of  all  viscera  the  heart 
is  the  most  sensitive  to  stimulation,  and  the  result  of 
stimulation  is  most  readily  recognised.  This  readi- 
ness to  respond  to  stimulation  is  necessary  to  the 
demands  of  the  economy,  for  it  is  on  this  account 
that  effort  can  be  undertaken  with  ease  and  comfort, 
the  heart  rate  increasing  with  the  demand  made  by 
effort.  The  heart  is  so  readily  susceptible  to  so 
many  influences  that  it  is  often  impossible  to  deter- 
mine the  mechanism  by  which  its  changes  in  action 
are  brought  about.  Mental  impressions  have  so 
powerful  an  effect  that  reactions  playing  first  upon 
the  mind  may  secondarily  affect  the  heart,  and  it  is 
difficult  in  many  cases  to  tell  whether  the  heart's 
stimulation  is  direct  or  secondary  to  the  mental 
stimulation.  Temperature  has  also  a  very  marked 
influence  on  the  heart  apart  from  the  toxins  which 
cause  the  rise  of  temperature.  Toxins  may  at  the 
same  time  have  an  influence  on  the  heart,  so  that  it 
is  im.possible  in  many  cases  to  tell  how  much  of  the 
heart's  reaction  is  due  to  the  rise  in  temperature, 


82  Chapter    VIII. 

and  how  much  to  the  infection.  Experimentally  it  is 
known  that  by  such  means  as  pinching  the  stomach 
wall,  reflex  stimulation  of  the  heart  takes  place 
through  vagus  excitation,  and  even  the  act  of 
swallowing  in  man  can  sometimes  be  shown  to  affect 
the  heart.  Hence  it  is  often  assumed  that  many  ab- 
normalities in  rate  and  rhythm  of  the  heart  are  of 
visceral  origin,  and  this  may  be  so,  as  one  sometimes 
finds  certain  irregularities  increased  by  stomach 
disorders.  Nevertheless  one  has  to  be  very  careful 
before  accepting  such  conclusions,  as  a  very  great 
many  abnormalities  in  the  heart's  action  are  attri- 
buted to  reflex  stimulation  when  the  real  cause  is  in 
the  heart  itself. 

46.  Vaso-motor  and  Pilo-motor  Reflexes. — 
The  peripheral  circulation  is  also  susceptible  to 
reflex  stimulation  through  the  influence  of  the  vaso- 
motor nerves.  Except  in  such  cases  as  flushing  and 
the  redness  or  heat  of  the  ears  or  of  the  cheek  in 
pulmonary  affections,  vaso-dilator  reflexes  are  not 
often  recognised.  Vaso-constrictor  effects  are  more 
common  though  they  have  not  been  sufficiently  in- 
vestigated. As  they  are  often  accompanied  by  the 
pilo-motor  reflexes  they  are  often  assumed  to  be  due 
to  the  pilo-motor  reflex.  Thus  the  sensation  accom- 
panying the  appearance  of  "  goose-skin  "  is  usually 
put  down  as  a  goose-skin  sensation.  Goose-skin  is 
due  to  the  contraction  of  the  muscles  attached  to  the 
hair  roots,  and,  doubtless,  their  contraction  does  give 
rise  to  a  sensation  as  when  one  feels  the  hair  rise 
on  the  scalp.  But  the  curious  chilly  sensation  is  due 
to  a  vaso-constrictor  effect,  for  it  can  be  felt  in 
regions  where  there  are  no  pilar  m.uscles,  as  on  the 
ulnar  border  of  the  hand.    The  explanation  I  suggest 


Organic  Reflexes.  83 

is  that  the  stimulation  which  causes  the  pilar 
contraction  causes  also  a  vaso-constriction,  for  the 
pilar  and  vaso-constrictor  nerves  both  belong  to  the 
autonomic  system,  and  are  associated  in  their  origin 
and  distribution.  This  association  is  well  brought 
out  in  the  following  experiment.  If  in  a  suitable 
case  the  skin  under  the  nipple  be  given  a  smart  rub 
with  a  piece  of  flannel,  the  goose-skin  will  be  seen 
to  arise  over  the  part  rubbed,  then  to  spread  up  the 
chest  to  near  the  clavicle,  and  on  to  the  inner  side  of 
the  upper  arm  and  forearm.  At  the  same  time  the 
individual  may  feel  the  curious  chilly  sensation 
passing  from  his  chest  into  his  arm  and  to  the  ulnar 
border  of  the  hand.  The  reason  for  this  distribution 
is  that  the  stimulus  produced  by  the  rubbing  has 
reached  in  the  spinal  cord  the  centres  of  origin  of 
the  pilo-motor  and  vaso-constrictor  nerves,  and 
passed  up  this  region  for  some  little  distance.  That 
this  is  so  can  be  inferred  from  the  fact  that  the 
pupil  will  be  seen  to  dilate  at  the  same  time.  The 
dilator  pupillae  nerve,  according  to  Langley,  leaves 
the  cord  at  the  place  where  this  stimulation  has 
taken  place — that  is  to  sa}^  by  the  upper  thoracic 
nerves.  In  one  instance,  a  patient  described  always 
a  chilly  sensation  in  his  cheek  when  I  tried  this  ex- 
periment on  him,  and  Sherrington  saj^s  that  in 
stimulating  the  sympathetic  fibres  issuing  with,  the 
third  thoracic  nerve  in  the  monkey,  he  produced 
elevation  of  the  hair  of  the  cheek. 


Chapter  TX. 

LAWS  DETERMINING  THE  NATURE  OF 
THE  REFLEX  SYMPTOMS. 

47.  Mechanism  of  the  production  of  "  direct  fain  " 

and  "  referred  j)ainJ^ 

48.  The    Viscero-motor  Reflex. 

49.  The  Organic  Reflexes. 

50.  Irritable  Foci  in  the  Spinal  Cord. 

5L      Exaggerated   Reflexes  due  to   Irritable   Foci  in 
the   Cord. 

52.      Relation  of    Visceral  Lesion  to  Site  of  Reflex. 

In  this  chapter  I  give  a  resume  of  the  fore- 
going observations  in  order  to  bring  clearly  forward 
the  mechanism  of  the  production  of  the  reflex 
symptoms. 

47.  Mechanism  of  the  production  of  "  direct 
pain  "  and  "  referred  pain." — From  what  has  been 
said  in  regard  to  the  production  and  recognition  of 
pain  it  will  be  realised  that  from  the  practical  and 
clinical  point  of  view  pain  can  arise  from  peripheral 
stimulation  in  two  ways,  what  may  be  called  "  direct 
pain  "  and  "  referred  pain."  Leaving  out  of  con- 
sideration the  pain  arising  from  direct  implication 
of  the  nervous  system  by  disease  (as  affections  in  the 
nerve-trunks  and  in  the  central  nervous  system),  and 
considering  only  the  pains  arising  from  stimulation 


Laws  determining  nature  of    Reflex  Symptoms.     85 

of  the  peripheral  distribution  of  the  cerebro- 
spinal and  of  the  sympathetic  nerves,  we  recognise 
that  pain  induced  in  either  case  is  always  accom- 
panied by  a  judgment  of  locality,  that  is,  the  pain  is 
referred  to  some  region  more  or  less  well  defined. 
There  is,  however,  this  difference— in  the  case  of  the 
cerebro-spinal  nervous  system  the  region  in  which 
the  pain  is  felt  is  the  region  in  which  the  painful 
stimulation  occurs,  whereas  in  the  sympathetic 
system  the  region  in  which  the  pain  is  felt  is  not 
the  region  in  which  the  painful  stimulus  occurs. 

The  mechanism  of  the  production  of  direct 
pain  (cerebro-spinal)  and  referred  pain  (sympa- 
thetic) can  be  shown  b}^  the  two  accompanying 
diagrams.  Fig.  3  represents  the  course  of  the  sen- 
sory and  motor  cerebro-spinal  nerves  from  their 
centres  in  the  spinal  cord  to  the  periphery.  If  a 
stimulus  be  applied  to  the  skin  (Sk),  the  sensation  is 
conveyed  by  the  sensory  nerve  (SN)  to  the  spinal 
cord,  and  up  to  the  brain.  The  brain  becomes  con- 
scious of  the  stimulus,  and  recognises  the  place  from 
which  the  stimulus  arose.  In  Fig.  4  there  is  added 
to  the  diagram  of  Fig.  3  two  organs  (V  and  V)  with 
sympathetic  nerves  (SyN)  passing  from  them  to  the 
spinal  cord,  and  these  nerves  terminate  in  cells  near 
to  the  motor  and  sensory  cells  connected  with  the 
motor  and  sensory  nerves  (MN,  SN). 

A  stimulus,  adequate  to  produce  pain,  arising 
in  the  organ  V  passes  to  the  spinal  cord,  extends 
beyond  its  own  nerve  cell  and  affects  neighbouring 
cells.  These  cells  being  thus  stimulated  respond 
according  to  their  function,  so  that  when  the  sensory 
cell  is  stimulated  pain  arises  and  the  brain  recog- 
nising this  pain  forms,  at  the  same  time,  a  judgment 


86 


Chapter  IX. 


Fig.  3. 

Diagram  to  represent  the  mechanism  of  pain  and  the  superficial  or 
skin  reflex  arising  from  stimulation  of  a  sensory  cerebro -spinal  nerve  (SN). 
An  adequate  stimvilus  applied  to  the  skin  (Sk)  or  to  any  part  of  the 
sensorj'  nerve  (SN)  in  the  external  body  wall,  spinal  cord  or  brain  is  per- 
ceived by  the  brain  (Br),  and  referred  to  the  peripheral  distribution  of  the 
nerve  in  the  external  body  wall  (Sk,  M).  The  stimulus  from  the  skin  may 
in  the  spinal  cord  pass  to  the  cell  of  a  motor  nerve  (MN)  and  simulating 
it  cause  a  contraction  of  a  muscle  (M). 


Laws  determining  nature  of    Reflex  Symptoms.     8' 


Fig.  4. 
Diagram  to  represent  the  mechanism  of  visceral  pain,  cutaneous  and 
muscular  hyperalgesia  (viscero-sensory  reflex),  the  viscero-motor  reflex,  and 
the  organic  reflex.  An  adequate  stimulus  proceeding  from  the  organ,  V, 
by  the  sympathetic  nerve,  SyN,  to  the  centre  in  the  spinal  cord  extends  to 
the  cells  of  nerves  in  its  neighbourhood,  and  stimulates  them  to  activity, 
when  the  fimction  peculiar  to  each  nerve  is  exhibited.  Thus  the  stimulus 
affecting  the  cells  of  a  pain  norve,  SN,  results  in  the  perception  of  pain 
which  is  referred  by  the  brain  to  the  peripheral  distribution  of  the  nerve 
in  the  external  body  wall  (Sk,M)  ;  affecting  the  cell  of  a  motor  nerve,  MN, 
causes  a  contraction  of  the  muscle,  M,  HU|)plied  by  the  motor  norve  ; 
affecting  the  colls  su])plying  other  viscera  (as  V")  stiniulates  them  to  their 
peculiar  fvmction  (contraction  of  a  hollow  muscular  viscus,  iiicroased 
secretion  of  a  secretory  organ).  If  the  stimulus  be  of  sufficient  strength 
it  may  leave  an  irritable  focus  in  the  spinal  cord  (shaded  area)  as  shown 
l)y  a  persistent  hyperalgesia  of  skin  and  muscle  (Sk,M)  and  by  a  persistent 
contraction  of  the  muscle  (M). 


88  Chapter  IX. 

of  locality.  That  locality,  however,  is  not  the  region 
where  the  pain  stimulus  arose  (organ  V),  but  at  Sk 
in  the  peripheral  distribution  of  the  sensory  nerve 
whose  centre  in  the  spinal  cord  had  been  stimulated. 
For  this  reason  visceral  pain  is  seen  to  be  of  the 
nature  of  a  viscero-sensory  reflex,  and  is  "  referred  " 
to  the  peripheral  distribution  of  the  sensory  cerebro- 
spinal nerves  whose  centre  in  the  spinal  cord  is  in 
close  association  with  the  sympathetic  centre 
supplying  the  offending  viscus. 

48.  The  Viscero-motor  Reflex.  —  In  diagram 
Fig.  3,  the  stimulation  of  the  skin  may  produce  other 
symptoms  than  that  of  pain  ;  it  may,  for  instance, 
produce  a  reflex  contraction  of  the  muscle  (M),  whose 
nerve  centre  in  the  spinal  cord  is  in  close  association 
with  that  of  the  sensory  nerve  (the  superficial  or 
skin  reflex).  In  a  like  manner  the  stim.ulation 
reaching  the  spinal  cord  from  the  organ  V  (Fig.  4) 
may  produce  a  reflex  contraction  of  the  same  muscle 
(the  viscero-motor  reflex).  It  is  this  reflex  that 
causes  the  hard  contraction  of  the  abdominal  muscles, 
or  some  portion  of  them,  in  disease  of  the  abdominal 
viscera  and  the  mechanism  of  their  production  is 
shown  in  Fig.  4. 

49.  The  Organic  Reflexes. — In  Fig.  4  there  is 
also  shown  in  the  spinal  cord  the  close  association  of 
the  nerve  centres  from  the  viscus  V  with  that  of  the 
viscus  V^  It  has  already  been  pointed  out  that  a 
stim.ulus  reaching  the  spinal  cord  may,  if  of  adequate 
strength,  stimulate  other  nerve  cells  in  its  neighbour- 
hood, and  these  respond  according  to  the  nature  of 
their  functions,  producing  pain  and  muscular  con- 
traction as  we  have  seen.  If  the  nerve  supply  of 
another  organ  be  stimulated,  then  that  organ  will 


Laws  determining  nature  of   Reflex  Symptoms.     89 

respond  according  to  its  peculiar  function,  so  that  in 
the  affection  of  one  viscus  we  may  get  reflex  stimula- 
tion of  other  viscera,  as  in  the  frequent  micturition 
from  stimulation  of  the  bladder  centre  in  appendi- 
citis, or  increased  flow  of  urine  or  saliva  in  angina 
pectoris.  Our  knowledge  of  the  exact  relationship 
of  nerve  centres  does  not  permit  of  the  real 
mechanism  being  always  ascertained,  but  the  clinical 
facts  point  to  a  relationship  as  in  the  production  of 
vomiting  from  organs  so  remote  as  the  testicle  and 
uterus. 

50.  Irritable  Foci  in  the  Spinal  Cord. — If  the 
symptoms  arising  in  cases  of  visceral  disease  be 
analysed  after  the  manner  in  which  a  focal  lesion  in 
the  brain  or  spinal  cord  is  analysed,  then  the  true 
nature  of  the  sjmiptoms  present  will  be  appreciated. 
This  manner  of  looking  at  the  subject  will  demor- 
strate  that  in  many  cases  of  visceral  disease  nearly 
the  whole  of  the  symptoms  present  are  really  due 
to  a  stimulation  of  a  limited  portion  of  the  central 
nervous  system.  Thus,  the  shaded  portion  of  the 
spinal  cord  in  Fig.  4  may  be  looked  upon  as  being 
rendered  abnormally  excitable  in  consequence  of  a 
violent  stimulation  from  the  organ  V.  All  the 
centres  in  this  region  become  abnormal^  sensitive  to 
stimulation,  and  this  is  recognised  b}^  the  exalted 
functions  of  organs  supplied  from  this  region  (hyper- 
algesia, muscular  contraction,  and  undue  activity  of 
other  organs). 

The  stimulus  that  has  had  so  marked  an  effect 
upon  the  spinal  cord  not  only  produced  the  charac- 
teristic reflexes  just  described,  but  has  rendered  the 
sensory  centre  abnormally  sensitive  so  that  the  area 
stimulated    is    left    in    a    condition    of    excessive 


90  Chapter  IX. 

irritability.  Thus,  the  hyperalgesia  of  skin  and 
muscle  that  is  often  so  marked  a  feature  in  visceral 
disease  is  due  to  the  fact  that  a  stimulus  which  would 
normally  produce  no  painful  sensation  on  reaching 
the  spinal  cord  excites  an  abnormally  sensitive 
centre,  with  the  result  that  the  sensation  of  pain  is 
felt.  That  this  is  the  explanation  is  shown  by  the 
further  fact  that  a  stimulus  reaching  this  excitable 
area  in  the  cord  from  other  sources  also  produces  pain 
which  is  referred  to  the  hyper  algesic  tissues  (skin  or 
muscle).  Thus,  in  a  case  of  gall-stone  colic,  accom- 
panied by  jaundice,  there  is  also  extreme  hyperal- 
gesia of  the  skin  of  the  upper  part  of  the  abdomen, 
especially  marked  in  the  epigastrium.  This  per- 
sisted for  some  days  after  the  stone  had  passed  and 
had  been  found  in  the  stool.  During  the  time  the 
hyperalgesia  persisted,  food  taken  into  the  stomach 
produced  severe  pain  referred  to  the  epigastrium. 
With  the  disappearance  of  the  hyperalgesia  of  the 
skin  the  pain,  on  taking  food,  ceased.  Here  there 
seem,s  little  doubt  that  the  stimulation  set  up  by  the 
ingestion  of  food,  which  normally  passes  to  the 
spinal  cord  unperceived  by  the  brain,  reached  that 
portion  of  the  cord  which  had  been  abnormally 
excited  by  the  gall-stone  colic.  The  irritable  focus 
thus  produced  in  the  cord  had  extended  to  the 
centres  of  the  cutaneous  nerves  for  pain  which 
supply  the  epigastric  region,  so  that  the  brain  now 
perceived  the  stimulation  as  pain  and  referred  it  to 
the  peripheral  distribution  of  the  nerves  thus 
stimulated. 

I  have  lately  been  observing  another  remarkable 
manner  in  which  these  abnormally  sensitive  foci  in 
the   cord   ma}^   be   stimulated.     My   attention   was 


Laws  determining  nature  of   Reflex  Symptoms.     91 

directed  to  this  aspect  of  the  question  by  the 
foUowing  experience :  A  lady  who  suffered  from 
endometritis  experienced  pain  in  her  back  across  the 
top  of  the  sacrum,  with  tenderness  and  stiffness  of 
the  muscles  of  the  back  in  the  lumbar  region.  She 
told  me  that  if  she  were  startled,  as  by  the  banging 
of  a  door,  a  pain  would  suddenly  shoot  into  this 
tender  region  of  the  back. 

I  have  made  inquiries  of  a  number  of  other 
patients,  and  have  found  abundant  corroboration  of 
this  experience  ;  so  much  so  that  many  people  in 
whom  there  is  a  hj^peralgesic  area  (cutaneous  or 
deeper)  experience  a  sudden  pain  in  that  region 
when  startled.  Thus,  one  patient,  who  suffers  from 
a  gastric  ulcer,  was  frightened,  on  her  way  to  con- 
sult me,  by  being  accosted  by  a  drunken  man,  and 
she  felt  a  severe  pain  in  the  epigastrium  at  the  same 
time.  In  her  case  there  was  a  great  tenderness  of  the 
skin  and  muscles  of  the  epigastrium  on  light  pres- 
sure. Another  patient,  with  a  dilated  heart  and 
great  tenderness  of  the  left  side  of  the  chest,  de- 
scribed how  someone  unexpectedly  laid  a  hand  upon 
her  shoukler,  so  that  she  started,  and  at  the  same 
time  a  severe  pain  struck  into  her  left  breast.  The 
explanation  I  give  for  the  occurrence  of  these  pains 
is  that,  Mlien  startled,  a  stimulus  passes  down  cer- 
tain tracts  of  the  spinal  cord,  affecting  normally  the 
centres  of  the  muscular  nerve  supply,  as  evidenced  by 
the  sudden  contraction  of  nearly  all  the  muscles  of 
the  body.  The  stimulus  is  not  of  sufficient  strength 
to  affect  the  sensory  nerves  in  a  healthy  cord,  but 
when  there  are  abnormally  irritable  foci  the  stimu- 
lus, passing  through  these,  affects  the  excitable 
sensory  nerve  centres,   and   the  pain   so   arising  is 


92  Chapter  IX. 

referred  to  the  peripheral  distribution  of  the  nerve 
stimulated.  It  may  be  that  the  pain  is  produced  by 
a  stronger  and  painful  contraction  of  the  excitable 
and  hyperalgesic  muscles. 

A  somewhat  similar  result  follows  on  extra 
stimulation  of  motor  nerves  whose  centres  are 
excited  by  visceral  stimulation.  When  there  is  an 
exalted  viscero-motor  reflex,  the  muscles  are  in  a 
permanently  more  contracted  condition  than  that 
which  the  normal  tonicity  maintains,  as  evidenced 
in  the  fiat  muscles  of  the  abdomen  by  the  greater  or 
less  hardness  with  which  we  are  all  familiar.  This 
is  due  to  their  being  exercised  in  their  function  as 
part  of  the  protective  mechanism.  If  now  they  be 
exercised  in  their  other  functions  by  assisting  in  the 
movements  of  the  body,  the  combined  result  of  these 
two  stimuli  is  to  produce  a  continuous  and  increased 
shortening  of  the  muscle.  This  was  remarked  in  the 
case  of  appendicitis,  cited  on  page  42,  where  the 
psoas  muscle  caused  the  patient  to  stoop  when  she 
walked  a  short  distance.  In  another  patient,  who 
suffered  from  renal  colic,  after  an  attack  had  passed 
there  always  persisted  for  a  few  days  a  slight  tender- 
ness and  rigidity  of  the  lower  part  of  the  right  rectus 
muscle.  When  he  went  about  the  whole  of  the  muscle 
became  so  contracted  after  a  few  hours  that  he  could 
not  straighten  himself,  but  walked  with  his  body 
slightly  bent.  After  a  short  rest  the  contracted 
muscle  would  slightly  relax.  A  similar  condition  is 
found  in  those  cases  of  "  lumbago  "  where  the  pain 
and  stiffness  of  the  muscles  arise  from  some  pelvic 
trouble — endometritis,   haemorrhoids,   etc. 

51.  Exaggerated  Reflexes  due  to  Irritable 
Foci  in  the  Cord. — In  all  these  hyperalgesic  areas 


Laivs  determining  nature  of    Reflex  Symptoms.     93 

due  to  a  focal  irritation  of  the  spinal  cord  the 
ordinary  cutaneous  reflex  is  more  easily  excited  and 
the  muscular  response  more  vigorous  and  often  more 
prolonged  than  normal.  I  need  not  labour  this  point 
as  the  fact  is  so  readily  demonstrated,  and  every  one 
is  familiar  with  the  hardening  of  the  abdominal 
wall  when  any  tender  part  is  palpated  with  even 
very  gentle  pressure.  This  springing  up  of  the 
hardened  muscle  serves  as  an  efficient  protection  of 
the  underlying  viscera,  and  the  purpose  of  the  cuta- 
neous and  muscular  hyperalgesia  is  manifestly  to 
render  the  reflex  muscular  contraction  rapid  and 
powerful.  In  severe  cases  this  muscular  contraction 
does  not  at  once  relax,  but  the  muscle  may  remain 
contracted  for  long  periods,  and  even  under  deep 
anaesthesia. 

52.  Relationship  of  Visceral  Lesion  to  Site 
of  Reflex. — Recognising  the  fact  that  the  pain  and 
other  sensory  phenomena  are  to  be  found  in  the 
peripheral  distribution  of  some  cerebro-spinal  sen- 
sory nerve,  it  is  necessary,  for  the  detection  of  the 
offending  viscus,  to  know  the  relationship  between 
the  distribution  of  the  cerebro-spinal  nerves  in  the 
external  body  wall  and  the  individual  organs.  In 
the  primitive  vertebrate,  before  the  development  of 
the  limbs,  each  spinal  nerve  is  distributed  round  the 
body.  The  sympathetic  nerves  supplying  the  viscera 
issue  from  the  cord  with  the  cerebro-spinal  nerve 
and  supply  the  viscera  at  the  same  level,  so  that  the 
nerve  supply  of  the  organ  and  the  nerve  supply  to 
the  covering  external  wall  arise  from  the  same  region 
of  the  spinal  cord. 

In  Fig.  5  there  is  a  diagi-am  showing  the  posi- 
tion of  the  heart  in  a  primitive  vertebrate.    From  the 


94 


Chapter  IX. 


Fig.  5. 

Diagrammatic  representation  of  a  primitive  vertebrate  animal — 
the  Amphioxus — divided  for  convenience  into  three  segments  for 
the  head,  seven  for  the  neck,  twelve  for  the  thorax,  nine  for  the 
lumbo-sacral  region,  and  an  indefinite  number  for  the  coccygeal  region. 
For  clearness  of  comparison  the  heart  (H)  is  represented  as  occupying 
the  same  position  as  in  man,  so  that  an  adequate  stimulus  from  the  heart 
would  cause  pain  in  the  distribution  of  the  four  upper  thoracic  nerves 
covering  and  protecting  the  heart.  Compare  distribution  of  thoracic 
nerves  with  Fig.  6.     (  After  Ross.) 


Laws  determining  nature  of    Reflex  Symptoms.     95 


Fig.  6. 

The  shaded  area  shows  the  distribution  of  the  pain  and  cutaneous 
hyperalgesia  in  a  typical  case  of  angina  pectoris.  The  ronian  numbers 
refer  to  the  nerves  implicated,  viz.,  I,  II,  III,  and  IV,  thoracic  nerves, 
and  VIII,  cervical  nerve.  Compare  the  nerve  distribution  with  Fig.  5,  and 
the  shaded  area  with  the  position  of  the  herpetic  eruption  in  Fig.  7. 


96  Chapter  IX. 

spinal  cord  the  nerves  pass  to  be  distributed  around 
the  body  wall.  In  addition  to  these,  a  branch  is 
given  off  which  runs  to  the  sympathetic  ganglia  to 
be  distributed  to  the  heart  (H).  When  a  stimulus 
of  adequate  strength  passes  from  the  heart  through 
the  sjmipathetic  to  the  spinal  cord  the  result  is 
shown  in  the  stimulation  of  the  sensory  and  motor 
nerves  arising  at  that  level,  so  that  these  reflex 
phenomena  are  exhibited  in  the  immediate  neigh- 
bourhood of  the  suffering  viscus. 

In  the  course  of  development,  particularly  with 
the  appearance  of  the  limbs,  this  relationship  of  the 
situation  of  the  viscus  to  the  distribution  of  the 
allied  cerebro-spinal  nerves  becomes  modified, 
although  the  relationship  of  the  spinal  and  sympa- 
thetic nerve  remains.  The  viscera  become  displaced 
backward,  and  the  nerves  that  were  wont  to  run 
transversely  round  the  body  at  the  level  of  their  exit 
from  the  cord  become  distributed  in  an  apparentl}^ 
irregular  fashion.  Thus,  the  lower  cervical  and 
upper  thoracic  nerves  are  distributed  mainly  in  the 
arm,  so  that  the  nerves  supptying  the  skin  over  the 
clavicle,  and  as  low  as  the  second  rib,  com,e  from 
the  fourth  cervical,  while  the  adjacent  skin  lower 
down  on  the  chest  is  supplied  from  the  second 
thoracic  nerve — the  intervening  nerves  being  distri- 
buted in  the  arm.  The  sympathetic  fibres  supplying 
the  heart  arise  from  the  spinal  cord  at  the  level  of 
the  upper  thoracic  nerves,  so  that  the  pain  in  affec- 
tions of  the  heart  is  felt  in  the  distribution  of  these 
nerves.  In  the  case  of  the  primitive  vertebrate 
represented  in  Fig.  5,  the  pain  would  be  over  the 
heart,  whereas  in  man  the  pain  is  felt  not  only  over 
the  heart,  but  in  the  arm,  where  the  upper  thoracic 


Laws  determining  nature  of    Reflex  Symptoms.     97 


Fig.  7. 

The  shaded  areas  show  the  distribution  of  the  eruption  in  a  case  of 
herpes  zoster  affecting  the  upper  thoracic  nerves.  (Compare  with  the 
area  of  hyperalgesia  in  Figs.  6  and  18) 


98  Chapter  IX. 

nerves  are  distributed,  and  tliis  accounts  for  the 
characteristic  distribution  of  the  pain  in  angina 
pectoris  (Fig.  6). 

In  herpes  zoster  there  is  an  inflammation  of  the 
gangha  on  the  posterior  roots  of  the  spinal  nerves, 
and  when  the  ganglia  on  the  upper  thoracic  nerves 
are  affected,  the  eruption  has  a  distribution  closely 
resembling  the  hypersesthetic  area  in  angina  pec- 
toris (compare  Fig.  7  with  Fig.  6). 

The  same  diversion  of  nerves  takes  place  in  the 
lumbar  region,  where  the  lumbar  plexus  is  distri- 
buted to  the  inferior  extremity,  and,  as  a  conse- 
quence, the  symptoms  of  visceral  disease  may  appear 
in  the  leg. 

In  addition  to  the  disarrangement  from  the 
primitive  plan  of  the  limb  nerve-supply,  the  organs 
themselves  have  shifted  their  position,  such  organs 
as  the  heart  and  stomach  being  situated  further 
back,  while  the  testicles  migrate  far  away  from  their 
embryonic  position. 

It  is  in  consequence  of  this  diversion  of  nerves 
and  displacement  of  organs  that  the  symptoms 
arising  from  a  viscus  may  be  exhibited  at  some 
considerable  distance  from  the  situation  of  the 
viscus. 


(     99     ) 


Chapter   X. 

PRELIMINARY    EXAMINATION    OF    THE 
PATIENT. 

53.  The  Patienfs  Appearance. 

54.  The  Patienfs  Sensations. 

55.  Facial  Aspect. 

56.  The  General  Condition. 

57.  A  Review  of  all  the  Organs. 

53.  The  Patient's  Appearance. — Before  enter- 
ing upon  the  physical  examination  of  the  patient,  the 
physician  ought  to  obtain  a  clear  and  comprehensive 
appreciation,  of  the  patient's  own  sensations.  I 
therefore  wish  to  insist  upon  the  importance  of  the 
preliminary  examination,  which  may  be  of  more 
value  in  arriving  at  a  correct  estimation  of  the 
patient's  condition  than  the  most  elaborate  methods 
of  physical  examination.  The  attempt  to  appreciate 
the  patient's  condition  should  begin  when  first  he 
presents  himself.  On  his  appearance  in  the  con- 
sulting room,  his  bearing,  his  gait,  the  condition  of 
his  respiration,  the  colour  of  his  face,  any  nervous 
peculiarity  in  his  manner  of  speech  and  behaviour, 
and  so  forth,  should  be  noted.  If  he  is  in  bed,  note 
the  position  he  assumes,  and  any  change  in  his  colour 
or  respiration  in  response  to  such  exertions  as  talk- 
ing or  turning  over.     By  habit  one  unconscioush' 


100  Chapter  X. 

notices  these  things,  and  as  the  exanaination  pro- 
ceeds, first  one  trivial  matter,  then  another,  may 
arise,  which  helps  materially  in  guiding  the  exam- 
ination, and  in  forming  the  final  opinion. 

54.  The  Patient's  Sensations.— After  ascertain- 
ing the  patient's  name,   age,   and  occupation,   ask 
him  to  describe  briefly  his  chief  symptoms.-    After 
this  inquire  into  the  history  of  any  previous  illnesses 
or  circumstances  that  may  have  a  bearing  on  his 
present  condition,  as  the  nature  of  his  work,  condi- 
tion of  worry,  bygone  adventures,  and  hereditar}^ 
pre-disposition.     The  data  thus  elicited  will  serve  as 
a   guide   to   a  further  inquiry  into  the   symptoms 
of   which  the  patient   complains.     This   should  be 
undertaken  with  the  greatest  minuteness,  and  the 
answers  should  be  precise  and  definite.     When  the 
patient  refers  to  his  sensations,  get  him  to  indicate 
the  location  by  placing  his  hand  over  the  region,  and 
on  no  account  be  content  with  his  assertion  that  his 
sensation    has    been    felt    in    some    viscus,    as    the 
stomach,   heart,   bladder.     When   any   disagreeable 
sensation  as  pain  is  complained  of,  get  a  clear  know- 
ledge of  the  very  earliest  circumstances  under  which 
it  was  produced,  the  situation  in  which  it  was  first 
felt,    and    the    areas    into    which    it    spread.       In 
the  same  way,  if  it  is  breathlessness,  the  first  sign  of 
its  appearance  and  the  circumstances  that  induced 
it.     In  putting  the  questions  the  doctor  should  have 
a  definite  purpose  in  view,  based  on  the  statements 
made,    but    the    questions    must    not    be    put    in 
such  a  manner  that  the  patient  will  divine  the  drift. 
It  may  be  necessary,  however,  to  ask  leading  ques- 
tions, when  it  is  suspected  that  other  symptoms  may 
have  been  present  which  the  patient  has  overlooked. 


Preliminary  Examination  of  the  Patient.      101 

For  instance,  I  have  found  patients  dwell  upon 
symptoms  referable  to  the  epigastric  region  and 
assumed  to  be  gastric  in  origin  ;  further  inquiry  as 
to  whether  there  had  been  any  pain  in  the  shoulder 
has  frequently  brought  forth  the  answer  that  severe 
pain  had  been  felt  on  the  top  of  the  right  shoulder, 
but  it  was  thought  to  be  rheumatic  or  neuralgic.  The 
recognition  of  this  pain  then  leads  to  the  suggestion 
that  all  the  symptoms  ma}^  be  due  to  gall-stones.  In 
the  same  way,  in  obscure  cases  of  pain  in  the  lower 
part  of  the  abdomen,  the  question  whether  the 
testicle  was  ever  sore  and  tender  has  sometimes 
brought  out  the  answer  that  the  breeches  seemed  at 
times  too  tight,  and  were  supposed  to  be  the  cause  of 
the  testicular  pain.  The  presence  of  this  testicular 
pain  in  such  cases  is  often  suggestive  of  renal 
calculus. 

It  will  be  frequently  found  that  the  symptom, 
such  as  pain  even  of  the  most  severe  type,  is  described 
so  vaguely  that  no  definite  idea  can  be  obtained  in 
regard  to  its  manner  of  onset,  site,  or  radiation.  In 
such  cases,  if  the  patient  be  asked  to  note  these  par- 
ticulars next  time  the  suffering  arises,  he  will  often 
be  able  to  give  a  very  clear  and  instructive  account 
of  his  symptoms. 

I  have  said  that  a  patient's  answer  that  pain,  or 
any  other  sensation,  was  felt  in  an  organ  should 
never  be  taken.  I  may  add  a  warning  to  the  doctor 
not  to  make  a  note  of  the  sensation  by  attributing 
it  to  an}^  viscus  ;  thus,  a  pain  should  not  be  noted  as 
felt  in  the  heart,  stomach,  liver,  or  lungs,  but  only 
in  the  region  indicated  by  the  patient's  hand,  for 
it  \\  ill  probably  be  found,  on  later  examination,  that 
the  disease  was  not  in  the  supposed  viscus.     In  oilier 


102  Chapter  X. 

words,  he  should  make  no  notes  that  might  prejudge 
the  nature  of  any  symptom  until  he  has  all  the  evi- 
dence before  him.  The  results  of  this  inquiry  will  be 
a  guide  in  the  physical  examination  of  the  patient, 
when  corroborative  evidence  may  be  found  in  areas 
of  hyperalgesia  of  the  skin  and  muscles,  in  con- 
tracted muscles,  or  in  functional  or  structural 
symptoms  in  certain  of  the  viscera. 

55.  Facial  Aspect. — The  first  glance  may  at 
once  dispel  the  consideration  of  a  large  group  of 
complaints,  as  when  a  face  is  healthy-looking  and 
well-nourished  there  is  no  need  to  fear  the  presence 
of  any  malignant  or  exhausting  complaint.  When 
there  is  an  absence  of  this  healthy  tinge  the  recogni- 
tion of  faint  and  subtle  changes  is  useful.  A 
slight  duskiness  of  the  cheeks  or  lips  indicates 
imperfect  aeration  of  the  blood,  and  leads  first  to  the 
consideration  of  the  pulmonary  or  circulatory  con- 
dition. A  faint  tinge  of  yellow  in  the  duskiness 
raises  the  suggestion  of  liver  engorgement.  This 
faint  yellow  tinge  is  present  in  many  conditions,  as  in 
pernicious  anaemia,  malarial  cachexia,  and  the 
cachexia  of  malignant  disease.  A  mere  suspicion  of 
jaundice  of  the  skin  and  conjunctiva,  as  in  certain 
cases  of  gall-stone  disease,  may  give  to  the  face  the 
suspicious  look  of  a  malignant  cachexia,  and  so  also 
will  certain  forms  of  heart  failure,  particularly  that 
form  which  is  often  accompanied  with  wasting.  In 
the  latter  case  the  evident  heart  trouble  gives  a  key 
to  the  nature  of  the  enlarged  liver,  which  is  usually 
present.  A  dirty  greyish  aspect  is  sometimes  seen 
in  aortic  disease. 

Pallor  is  a  common  feature,  and  while  it  may 
indicate  an  anaemia  (as  chlorosis),  yet  it  is  natural 


Preliminary  Examination  of  the  Patient.     103 

to  many  families,  and  one  not  infrequently  sees  such 
people  undergoing  treatment  for  "  anaemia."  In 
elderly  people  the  pallor  may  indeed  be  associated 
with  various  complaints,  and  it  is  often  difficult  to 
tell  what  importance  should  be  attached  to  the  symp- 
tom. I  think  on  the  whole  the  presence  of  a  sallow 
tinge  is  the  most  constant  sign  of  malignancy- 
bearing  in  mind  what  I  have  just  said  of  the  presence 
of  a  slight  jaundice  in  heart  affections  and  gall-stone. 
When  people  past  the  middle  age  suddenly  develop 
a  pallor,  the  sign  is  one  of  grave  significance,  and 
may  be  the  first  clue  to  the  beginning  of  some 
malignant  affection  (pernicious  anaemia).  Other 
conditions  should  be  recognised,  as  the  flushed  turgid 
countenance  of  Graves'  disease.  Staring  eyes, 
while  manifestly  indicating  the  nature  of  the  com- 
plaint, may  not  be  very  distinctive,  but  a  slight 
prominence,  which  may  momentarily  increase  while 
the  patient  is  being  questioned,  may  be  detected. 

It  is  not  possible  here  to  detail  the  many  other 
instructive  signs  which  the  facial  aspect  pre- 
sents, but  I  quote  the  foregoing  as  being  the 
most  common,  and  would  insist  on  the  routine 
study  of  the  face  all  the  time  the  patient  is  being 
questioned.  As  a  disease  progresses  the  facial 
aspect  should  be  watched.  In  some,  particularly  in 
cliildren,  a  sunken  expression  may  appear  in  the 
course  of  an  attack  of  diarrhoea  or  pneumonia,  due 
to  a  shrinking  of  the  contents  of  the  orbit  and  of 
the  cheeks — often  heralding  a  fatal  issue.  In  the 
course  of  a  typhoid  fever  the  dull  look  of  indifference 
may  gradually  be  seen  to  creep  over  the  face.  A 
gradual  change  in  colour  may  be  imperceptible  to 
tlie  doctor  wlio  sees  the  patient  day  by  day,   but 


104  Chapter  X. 

is  marked  at  once  by  one  who  sees  the  patient  for  the 
first  time,  and  this  change — a  shght  pallor,  or  a 
slight  yellow  tinge — may  be  the  earliest  sign  of  a 
malignant  disease   (pernicious  anaemia,   cancer). 

56.  The  General  Condition.— It  is  undoubtedly 
a  misfortune  that  the  study  of  what  is  called  "  tem- 
peraments "  has  fallen  into  disuse.  My  own  experi- 
ence tells  that  the  neglect  of  this  basis  of  observation 
is  continually  leading  physicians  and  surgeons  astray. 
This  is  particularly  the  case  with  those  who  devote 
themselves  to  some  speciality.  The  possession  of 
certain  temperaments,  particularly  the  neurotic, 
leads  to  exaggeration  of  the  reflex  symptoms,  and  a 
trifling  complaint  is  thus  often  mistaken  for  some- 
thing more  serious.  We  find  such  patients  passing 
from  one  specialist  to  another,  each  one  attributing 
the  complaint  to  the  fault  of  some  organ  which  came 
under  his  special  purview. 

Although  it  may  not  be  possible  to  differentiate 
exactly  the  six  temperaments  of  Laycock  (nervous, 
sanguine,  phlegmatic,  bilious,  lymphatic,  and  melan- 
cholic), yet  the  consideration  of  each  individual's 
temperament  should  help  us  to  estimate  at  its  due 
value  the  patient's  symptoms  and  the  account  of  his 
or  her  sufferings.  While  we  may  not  be'  able  to 
classify  temperaments  with  accuracy,  yet  in  every 
case  the  mental  attitude  of  the  patient  to  his  com- 
plaints should  be  borne  in  mind.  Although,  in  a 
general  way,  each  individual  is  so  constituted  that 
his  temperament  is  a  matter  of  inheritance,  yet  it 
can  be  modified  by  circumstances.  This  is  particu- 
larly seen  in  people  who  become  "  neurotic "  in 
consequence  of  mental  worry  or  long  continuous 
bodily  suffering. 


Preliminary  Examination  of  the  Patient.     105 

The  characteristics  of  a  patient's  temperament 
come  out  generally  in  the  course  of  the  preliminary 
examination,  in  the  manner,  movements,  and  descrip- 
tion of  the  complaints. 

57.  A  Review  of  all  the  Organs.  —  In  the 
examination  of  patients  the  need  for  a  thorough 
inquiry  may  demand  that  all  organs  should  be  in- 
quired into.  It  is,  however,  not  feasible  or  even 
necessary  in  the  great  majority  of  cases  to  make  a 
systematic  examination  into  the  condition  of  each 
organ. 

In  an  obscure  case,  and  in  cases  where  there  is 
some  complication,  and  when  there  is  time  and 
opportunity,  no  examination  can  be  too  careful  or 
too  thorough.  But  the  great  majority  of  cases  with 
which  the  general  practitioner  has  to  deal  do  not 
present  such  complicated  features,  and  the  pre- 
liminary inquiry  into  the  patient's  symptoms  gives 
a  clue  to  the  organ  chiefly  at  fault,  so  that  it  is 
unnecessary  that  all  the  other  organs  should  be 
submitted  to  a  detailed  physical  examination.  It 
is  difficult  to  be  certain  when  such  thorough  exami- 
nation may  be  considered  unnecessary,  since,  through 
its  neglect,  many  ailments  may  be  overlooked.  To 
guard  against  this,  many  general  practitioners  have 
devised  for  themselves  methods  which  serve  to  guide 
them  in  the  detection  of  affections  of  organs  other 
than  that  of  which  complaint  is  made. 

In  the  logical  and  thorough  cross-examination 
to  which  the  patient  is  first  submitted,  a  fair  idea 
can  generally  be  obtained  of  the  organ  or  region  in 
which  there  is  trouble.  Before  examining  more 
specially  that  part,  inquir}'  should  be  made  into  the 
functions  of  other  organs.     These  may  be  at  fault. 


106  Chapter  X. 

and  ma}^  in  reality  be  the  real  seat  of  the  trouble, 
and  the  patient,  in  describing  the  more  prominent 
features  of  his  complaint,  may  have  ignored  some, 
to  him,  trivial  sign,  which  the  systematic  interroga- 
tions may  bring  out.  This  inquiry  need  not  be  time- 
robbing  if  the  physician  makes  his  questions  clear 
and  distinct,  and  insists  that  the  patient's  replies 
should  be  precise  and  to  the  point.  In  his  inquiries 
the  physician  should  have  some  system  in  his  own 
mind,  so  that  each  question  bears  upon  the  symp- 
toms of  a  single  organ  and  has  a  definite  significance. 
Thus,  after  having  exhausted  the  information  of  the 
particular  complaint,  and  having  observed  in  the 
course  of  his  inquiry  the  general  aspect  of  the 
patient,  as  already  described,  he  should  then  care- 
fully inquire  into  the  condition  of  other  organs, 
beginning  as  a  rule  with  those  related  by  position  or 
function  to  the  complaint  of  the  patient.  Step  by 
step  each  organ  is  considered,  and  any  that  may 
show  evidence  of  derangement  are  reserved  for  fuller 
investigation.  To  do  this  the  essential  symptoms  of 
derangement  of  any  organ  must  be  kept  in  view. 
Thus,  an  inquiry  is  made  into  the  condition  of  the 
heart  and  circulation  by  asking  if  the  breathing  in 
response  to  effort  is  good,  or  if  he  has  palpitation  or 
breathlessness  on  running  up  stairs,  beyond  that, 
which  one  would  expect  from  his  age  and  habits  ; 
into  the  lung  condition  by  the  presence  of  a  cough,  or 
of  trouble  in  the  breathing ;  into  the  digestive 
system  by  the  presence  of  discomfort  at  any  time 
before  or  after  meals,  and  by  the  movement  of  the 
bowel ;  into  the  urinary  system  by  the  frequency  of 
micturition,  and  particularly  as  to  whether  the  patient 
has  to  get  up  in  the  night  to  pass  urine.     By  following. 


Preliminary  Examination  of  the  Patient.     107 

such  lines  as  these,  being  often  guided  by  some 
incident  in  the  patient's  historj"  or  appearance,  it  will 
usually  be  found  that  no  essential  sign  is  overlooked. 
In  all  cases  the  patient's  replies  must  be  as  direct  and 
to  the  point  as  the  question  asked.  The  tendency  to 
prolixity,  which  many  patients  show,  must  be  firmly 
repressed  ;  a  clear  reply  should  be  obtained  to  each 
question,  and  no  question  allowed  to  pass  until  the 
answer  is  obtained.  The  patient  may  be  so  full  of 
his  own  view  as  to  his  condition  that  there  may  be 
some  difficulty  in  restricting  him  to  the  subject  the 
ph^^sician  has  in  his  mind,  but  if  the  phj^sician  will 
but  be  persistent  in  his  method — having  a  clear 
conception  in  his  own  mind  as  to  what  he  requires — 
the  patient  can  usually  be  induced  to  give  clear  and 
coherent  replies.  According  to  the  tenor  of  the 
replies  the  subsequent  phj^sical  examination  will  be 
guided.  In  drawing  conclusions  from  the  results  of 
the  examination  it  is  necessary  to  consider  the 
bearing  of  any  abnormality,  or  supposed  abnor- 
mality, on  the  sufferings  of  the  patient.  It  often 
happens  that  the  complaint  from  which  the  patient 
suffers  is  obscure,  and  the  cause  difficult  or  impos- 
sible to  determine.  Should  some  other  abnormality 
be  present,  which  is  easily  recognisable,  then  there 
is  a  great  tendency  to  attribute  the  symptoms  to  this 
demonstrable   abnormalit}'. 

A  patient  of  mine,  suffering  from  some  obscure 
abdominal  complaint,  consulted  a  gynecologist,  who, 
finding  an  ovary  which  he  considered  too  large,  put 
all  the  trouble  and  suffering  down  to  this,  and 
removed  it.  Obtaining  no  relief,  the  patient  sought 
tlie  opinion  of  a  surgeon,  who,  finding  a  slight  dila- 
tation of  the  stomach,  put  all  the  symptoms  down 


108  Chapter  X. 

to  that,  and  performed  a  gastro-enterostomy,  also 
without  reHef  to  the  patient.  In  youth  and  in  old 
age  certain  forms  of  irregularity  of  the  heart  are 
present  in  so  many  people  that  they  may  almost  be 
looked  upon  as  normal,  and  have  no  important  bear- 
ing upon  the  patient's  condition,  yet  when  these 
patients  are  found  suffering  from  any  obscure 
condition,  as  weakness,  fainting,  or  even  epilepsy, 
the  diagnosis  is  often  based  upon  this  irregularity, 
though  its  nature  is  not  understood.  To  many 
minds  it  is  satisfying  to  detect  an  abnormal  sign, 
even  though  it  has  no  connection  with  the  complaint 
from  which  the  patient  suffers.  This  tendency  to  be 
misled  by  the  detection  of  an  abnormal  sign  is  seen 
very  frequently  in  patients  who  may  have  a  cardiac 
murmur.  All  sorts  of  symptoms  can  be  referred 
back  to  this,  and  treatment  for  an  innocent  murmur 
is  often  undertaken  with  unnecessar}^  energy  to  the 
neglect  of  the  essential  cause  of  the  patient's  suffering 
{see  Chapter  XXI.). 


(     109     ) 


Chapter    XL 

SYMPTOMS    OF    AFFECTIONS    IN 

THE    REGION    OF    DISTRIBUTION    OF 

CEREBRO-SPINAL    NERVES. 

58.  Headache. 

59.  Sensory  and  Motor  Symptoms. 

60.  Differential   Diagnosis. 

The  functional  and  organic  symptoms  of  affec- 
tions of  the  external  body  waU  and  the  Umbs  are 
usually  so  manifest  that  it  is  not  necessary  to  deal 
with  them.  Here  certain  phenomena  are  discussed, 
connected  more  particularly  with  the  reflex  sensory 
symptoms. 

There  are  many  phenomena  resulting  directly 
from  stimulation  of  some  part  of  the  external  body 
wall  and  limbs  which,  at  first  sight,  are  not  easily 
understood,  and  often  simulate  the  sj^mptoms  of 
visceral  disease.  It  is  necessary  to  allude  briefly  to 
the  more  important  of  these. 

58.  Headache.  —  There  is  much  obscurity  in 
regard  to  the  mechanism  by  which  tlie  pain  of 
headache  is  produced.  I  have  made  a  number  of 
observations  in  all  kinds  of  headache,  and  must 
confess  that  I  see  no  clear  explanation.  The  con- 
ditions inducing  the  headache,  or  associated  with  it, 
are  so  varied  tliat  all  sorts  of  theories  can  point  to 
some  circumstances  for  their  support. 


110  Chapter  XI. 

Certain  forms  of  headache  stand  out  very  dis- 
tinctly, and  are  of  considerable  diagnostic  value, 
such  as  the  headache  associated  with  cerebral 
tumour,  kidney  disease,  migraine.  Others  may  arise 
reflexly  from  some  peripheral  irritation,  as  eye- 
strain, but  I  am  somewhat  doubtful  of  these  cases 
said  to  arise  reflexly  from  more  distant  organs,  as 
from  the  abdominal  viscera.  A  stomach  headache  is 
the  most  common,  but  as  absorption  of  toxins  takes 
place  so  readily  from  the  digestive  tract,  I  am  not 
clear  as  to  the  real  nature  of  headache  of  this  class. 

The  real  confusion  arises  because  of  our  in- 
ability to  identify  the  structures  in  which  the  pain 
is  felt ;  whether,  for  instance,  it  is  in  the  scalp  or  in 
the  membranes  of  the  brain,  or  whether  the  real  seat 
may  be  in  the  central  nervous  system.,  and  the  pain 
referred  to  the  periphery.  Whether  the  membranes 
of  the  brain  are  sensitive  or  not  still  seems  to  be  a 
matter  of  some  doubt,  and  personally,  I  have  not  had 
sufficient  opportunity  of  testing  these  membranes. 
Even  if  it  were  the  scalp  in  which  the  pain  was  felt, 
Ave  would  have  to  question  and  consider  what  part 
of  the  nerves  is  stimulated,  whether,  for  instance, 
their  peripheral  distribution,  or  some  deeper  part. 
The  variations  of  pain  in  the  head,  as  felt  by  indi- 
viduals, would  seem  to  point  to  the  stimulation 
arising  in  different  places,  and  it  is  probably  for 
this  reason  that  so  many  theories  can  be  found  to 
explain  headache. 

59.  Sensory  and  Motor  Symptoms. — The  view 
here  expressed  that  pain  is  a  function  peculiar  to 
certain  nerves  of  the  cerebro-spinal  system  necessi- 
tates the  consideration  whether  any  given  pain  is 
referred  {i.e.,  originates  reflexly  from  some  viscus), 


■Sym'ptoyns  of  Affections  of  Cerebrospinal  Nerves.   Ill 

whether  it  is  due  to  some  lesion  of  the  tissues  sup- 
plied by  the  sensory  nerve,  or  whether  it  arises  from 
some  affection  of  the  nerve  itself.  In  considering 
this  subject  it  must  be  remembered  that  pain  stimuli 
originating  in  the  external  body  Avail  may  be  referred 
to  other  parts,  and  may  be  accompanied  by  muscular 
contractions — symptoms  of  the  same  nature  and 
mechanism  as  the  viscero-sensory  and  viscero-motor 
reflexes.  This  is  notably  the  case  in  joint  affections, 
where  the  pain  is  not  infrequently  referred  to  areas 
at  some  distance  from  the  joint.  The  best  instance 
is  the  pain  felt  on  the  inner  side  of  the  knee  in 
disease  of  the  hip  joint.  As  a  matter  of  fact  the 
pains  caused  by  joint  affections  are  nearly  all  felt  at 
some  distance  from  the  joint.  Thus,  pain  in  affec- 
tions of  the  shoulder  joint  may  be  felt  down  the  arm 
as  low  as  the  elbow,  and  the  pain  from  the  knee  joint 
may  be  referred  over  the  head  of  the  tibia.  In  many 
joint  affections  the  contractions  of  the  muscles  that 
move  the  joint  may  be  so  strong  as  to  lead  to  the  idea 
that  the  joint  is  ankylosed.  This  is  particular^ 
the  case  with  some  affections  of  the  shoulder  joint. 
The  joint  may  be  immobile  until  the  patient  is  deeply 
under  chloroform,  when  it  will  be  found  freely 
movable.  There  can  be  little  doubt  that  the  pain  and 
the  muscular  contraction  are  due,  not  to  a  local 
stimulation  of  the  peripheral  nerve,  but  to  a  central 
stimulation.  Hilton  had  called  attention  to  the 
resemblance  of  the  symptoms  in  joint  affections  to 
those  of  affections  of  serous  cavities  like  the  abdo- 
men, and  there  can  be  little,  if  any,  doubt  that  he  was 
right.  In  hip-joint  disease  the  pain  in  the  neighbour- 
hood of  tlie  knee  is  usually  put  down  to  a  stimulation 
of  a  periplieral  nerve  that  supplies  tlie  skin  on  tlie 


112  Chapter  XL 

inside  of  the  knee,  but  though  the  pain  is  felt  in  the 
distribution  of  this  nerve,  the  real  explanation  is  that 
there  has  passed  from  the  hip  joint  into  the  spinal 
cord  a  stimulus  which  has  excited  the  cord  at  the  level 
from  which  the  obturator  nerve  arises.  At  this  level 
there  also  pass  out  the  nerves  supplying  the  muscles 
around  the  hip  joint,  so  that  in  addition  to  the  pain 
there  is  the  stiffness  and  contraction  of  these  muscles 
which  modifies  the  gluteal  fold.  This  stiffness  is 
comparable  to  the  slight  hardening  or  increase  in 
tone  of  the  flat  abdominal  muscles  in  visceral 
disease,  while  the  permanent  contraction  is  like  the 
hardened  abdominal  muscles  in  visceral  disease,  and 
the  conditions  are  really  due  to  an  hritable  focus  in 
the  spinal  cord  at  the  level  of  the  third  or  fourth  lum- 
bar segment  produced  by  the  lesion  in  the  hip  joint. 

This  view  of  the  cause  of  symptoms  opens  up 
the  question  of  the  nerve-supply  of  joints  and  the 
sensitiveness  of  fche  synovial  membrane.  I  lean  to 
the  idea  that  the  synovial  membrane,  like  the  peri- 
toneal, is  insensitive  to  direct  stimulation,  and  that 
the  pain  arising  from  its  stimulation  is  referred. 
This  may,  perhaps,  mean  that  the  nerve-supply  of  the 
joint  arises  not  from  the  cerebro-spinal  nervous 
system,  but  from  the  autonomic.  Pain  may  arise 
from  the  contraction  of  muscles  due  to  an  increased 
sensibility  of  the  muscle,  as  well  as  from  irritability 
of  the  nerve-centres,  as  in  reflex  hyperalgesia.  In 
certain  forms  of  rheumatism  muscular  contraction 
may  be  present,  giving  rise  to  the  "  stiffness  "  in  the 
joints,  best  observed  after  a  long  rest.  With  gradual 
exercise  of  the  muscles  the  stiffness  passes  off. 

Pain  may  arise  from  violent  spasmodic  contrac- 
tion of  the  muscles,  as  in  cramp.    The  pain  in  what 


Symptoms  of  Affections  of  Cerebrospinal  Nerves.   113 

is  called  muscular  rheumatism  is  often  due  to  con- 
traction of  voluntary  muscles,  as  in  lumbago, 
stiff-neck,  pluerodynia. 

While  these  contractions  are  usually  due  to 
some  temporary  affection  of  the  muscles,  similar 
contractions  may  arise  from  irritation  of  the  motor 
nerves  by  some  disease  process  as  spinal  caries. 

80.  Differential  Diagnosis. — On  account  of  the 
fact  that  pain  originating  in  any  part  of  a  nerve 
in  its  course  from  the  brain  to  its  periphery  is 
referred  to  its  peripheral  distribution,  there  is  often 
a  difficulty  in  determining  the  source  of  the  pain 
stimuli.  The  differential  diagnosis  must,  therefore, 
depend  on  a  knowledge  of  how  the  pain  arises,  the 
relationship  of  the  nerve-supply  of  different  regions 
of  the  body  to  the  central  nerve-supply,  and  its 
connection  wdth  the  visceral  nerve-supply.  In  the 
absence  of  any  demonstrable  cause  of  stimulation  at 
the  periphery,  it  is  necessary  to  consider  the  possi- 
bility of  stimulation  at  more  central  parts.  The 
symptoms  that  may  arise  from  an  irritation  of  a 
nerve-trunk,  as  from  pressure,  neuritis,  or  herpes 
zoster,  resemble  in  a  great  many  respects  those  that 
arise  from  visceral  disease.  So  great,  indeed,  is 
this  resemblance  that  even  the  most  experienced  may 
be  led  astray.  Thus,  the  pain  and  hyperalgesia  of  a 
stomacli  affection  may  simulate  the  symptoms 
produced  by  caries  of  tlie  spine  {see  page  70),  and  the 
shoulder-pain  of  gall-stone  disease  may  be  mistaken 
for  a  neuritis. 

It  might  have  been  supposed  that  pain  due  to 
the  stimulation  of  a  nerve  at  its  periphery,  or  at  its 
trunk,  would  have  liad  a  distribution  peculiar  to 
tlio  peripheral  distribution  of  the  nerve  branch  so 


114  Chapter  XI. 

stimulated.  If  the  region  of  the  pain  had  been 
limited  to  the  part  of  the  periphery  stimulated,  or 
to  the  distribution  of  the  nerve  trunk,  such  a  limita- 
tion of  the  field  of  pain  and  hyperalgesia  might  have 
given  the  desired  indication,  but,  as  has  already 
been  shown  (page  29),  the  stimulation  of  the  peri- 
phery of  a  sensory  nerve,  or  of  its  trunk,  causes  a 
spreading  of  the  pain  by  reason  of  a  central  radia- 
tion. It  foUows  that  a  local  irritation  may  produce 
such  widespread  phenomena  as  to  simulate  central 
irritation.  It  is  for  this  reason  that  the  various 
forms  of  "  neuritis  "  so  closely  resemble  the  pains  of 
visceral  disease,  pains  due  to  pressure  on  the  trunk 
of  the  nerve,  or  herpes  zoster. 

For  the  purpose  of  differential  diagnosis  it  is 
necessary  to  know  how  the  pains  of  visceral  disease 
arise  and  spread.  This  knowledge  can  only  be 
acquired  by  careful  study  of  individual  cases,  for 
though  certain  general  laws  underlie  the  production 
of  these  symptoms,  there  are  differences  in  individual 
cases.  In  doubtful  cases  the  knowledge  that  in 
visceral  disease  certain  associated  phenomena  can 
arise  may  often  help  to  clear  up  a  doubtful  case.  So 
far  as  I  can  I  deal  with  the  characteristics  of  the 
symptoms  in  the  organs  I  have  been  able  to  study. 
This  description  is  far  from  complete,  and  does  not  take 
into  consideration  symptoms  that  arise  from  certain 
viscera  (as  the  pancreas  or  spleen),  because  I  have  had 
no  opportunity  of  studying  the  symptoms  in  these 
cases  with  sufficient  precision,  and  the  descriptions 
usually  given  are  too  indeterminate  to  be  of  real  value. 

Before  deciding  that  any  given  case  is  a  neuritis 
or  a  neuralgia,  the  possibility  of  visceral  disease 
should  be  carefully  considered. 


(     115     ) 


Chapter  XII. 

AFFECTIONS   OF  THE   DIGESTIVE   ORGANS. 

61.  The  Nerve  Supply  of  the   Digestive  Tract. 

62.  Distribution     of     Sensory     Symptoms     in 

affections  of  the    Digestive    Tract. 

63.  Appetite. 

64.  Hunger. 

65.  Nausea. 

66.  Mouth  and  Fauces. 

67.  Tongue. 

68.  Swallowing. 

69.  (Esophagus. 

61.  The  Nerve  Supply  oi  the  Digestive  Tract.^ 

The  nerve  supply  of  the  digestive  tract  is  derived 
partly  from  the  autonomic  and  partly  from  the 
cerebro-spinal  system.  If  one  glances  at  Langlej^'s 
diagram  it  will  be  seen  that  the  autonomic  supply 
is  derived  from  three  regions  :  (1)  from  the  bulbar 
autonomic  division  by  the  vagus,  distributed  to 
the  walls  of  the  gut  from  mouth  to  descending 
colon  ;  (2)  from  the  sympathetic  cU vision  b}'  the 
splanchnics,  which  supply  the  stomach,  smaU  intes- 
tine, and  greater  part  of  the  great  intestine  ;  and 
(.3)  from  the  sacral  autonomic  division,  which  sup- 
plies the  descending  colon  and  rectum. 

The  cerebro-spinal  nerve  supply  is  limited  to 
the  oral  and  anal  orifices.     The  sensations  at  the 


116  Chapter  XII. 

oral  end  are  divided  into  those  of  common  and 
special  sensations.  The  sensory  nerves  are  derived 
from  the  fifth  cranial  and  glosso-pharyngeal,  and 
supply  the  mouth,  fauces,  and  a  small  portion  of 
the  upper  end  of  the  oesophagus  ;  the  exact  extent 
has  not  been  accurately  defined.  The  mouth  differs 
from  the  skin  in  sensibility,  touch  being  less  acute 
and  less  perfectly  localised,  though  temperature 
and  pain  senses  are  well  developed.  The  nerves  of 
special  sensibility  (taste)  in  the  tongue  are  derived 
from  the  glosso-pharyngeal,  fifth,  and  chorda  tym- 
pani  nerves.  The  olfactory  nerve,  too,  must  be  con- 
sidered as  an  accessory  nerve  of  digestion,  for  it  has 
remarkable  effects  in  stimulating  reflexly  the  salivary 
and  gastric  glands,  and  also  in  the  appreciation  of 
flavour.  It  has  also,  at  times,  a  powerful  effect  in 
inducing  attacks  of  vomiting. 

The  distribution  of  the  cerebro-spinal  system 
of  nerves  to  the  anal  end  of  the  gut  is  of  very 
small  extent,  being  limited  to  little  more  than  the 
inner  side  of  the  external  sphincter.  So  far  as  I 
have  been  able  to  make  out,  the  mucous  membrane 
covering  the  internal  sphincter  is  devoid  of  direct 
sensation. 

62.  Distribution  of  Sensory  Symptoms  in 
affections  of  the  Digestive  Tract. — The  nature  of 
the  nerve  supply  explains  the  character  of  the 
sensory  symptoms  evoked  by  affections  of  the  diges- 
tive tract.  Limiting  the  study  at  present  to  the 
subject  of  pain,  it  will  be  found  that  from  the  top 
of  the  oesophagus  to  the  anus  there  is,  in  the  great 
majority  of  instances,  a  limitation  of  the  distribu- 
tion of  the  pain  to  an  area  extending  down  the 
centre  of  the  body  from  about  the  middle  of  the 


Affections  of  the    Digestive    Organs.         117 


Fig.   8. 


The  shaded  parts  show  the  areas  in  which  jiain  is  felt  in  affections 
of  the  digestive  tnbe.  Peristalsis  ))assing  through  the  whole  digestive 
tube  may  give  rise  to  pain  felt  descending  in  the  shaded  area. 

A.  Area  in  which  i>ain  is  felt  in  affections  of  the  oesophagus. 

B.  Area  in  which  pain  is  folt  in  affections  of  the  stomach. 

C   Area  in  which  pain  is  fdlt  in  affections  of  the  small  intestine. 
D.   Area  in  which  pain  is  foit  in  affections  of  the  large  intestine. 


118  Chapter  XIL 

sternum  to  the  symphysis  pubis  (shaded  area  in 
Fig.  8). 

If  pain  be  produced  by  stimulating  the 
oesophagus,  as,  for  instance,  by  a  hot  drink,  the  pain 
is  alwa3^s  referred  to  the  region  over  the  lower  part 
of  the  sternum.  Usually  this  pain  is  supposed  to 
be  perceived  "  in  the  oesophagus,"  but  if  this  sensa- 
tion were  in  the  oesophagus  there  is  no  reason  why  it 
should  not  be  felt  better  in  the  back,  for  the  oeso- 
phagus is  nearer  the  posterior  cutaneous  surface 
than  the  anterior.  Pain  arising  from  the  stomach 
is  limited,  in  the  vast  majority  of  cases,  to  the 
epigastrium.  The  best  idea  of  intestinal  pain  is 
found  in  watching  a  case  of  peristalsis  of  the  bowel. 
A  painful  peristalsis  may  start  with  pain  referred 
to  the  lower  part  of  the  epigastric  region,  then 
it  slowly  descends  with  a  grinding  intermitting 
severity  until  it  reaches  above  the  pubes,  when  the 
call  to  defecate  becomes  urgent,  and  rehef  is  at  once 
found  with  the  expulsion  of  a  loose  motion.  In 
such  an  instance  the  fluid  has  traversed  the  whole 
intestinal  tract,  and  the  peristaltic  waves  have 
passed  into  all  quarters  of  the  abdominal  cavity,  yet 
the  pain  has  descended  in  an  even  and  unvarying 
direction  down  the  centre  of  the  abdominal  wall. 

It  is  well  to  remember  this  feature  of  pain  due 
to  peristaltic  contraction  of  the  gut,  for  it  will  be 
found  of  frequent  diagnostic  importance  in  solving 
the  source  of  severe  colic-like  pains.  As  already 
remarked,  contraction  of  non-striped  muscles  is  the 
most  frequent  cause  of  violent  visceral  pain,  and,  as 
a  rule,  when  the  pain  is  violent,  it  can  be  very 
accurateh^  localised.  This  limitation  of  the  pain  to 
the  middle  line  of  the  body  is  characteristic  also  of 


Affections  of  the   Digestive  Organs.  119 

the  pain  of  other  hollow  viscera,  as  the  gall-ducts, 
uterus,  and  bladder,  while  the  pain  of  renal  colic 
(contraction  of  the  ureter  and  pelvis  of  the  kidney) 
is   distinctly   unilateral. 

63.  Appetite. — All  actions  that  are  performed 
periodically  or  intermittently,  in  wliich  volition  par- 
ticipates, are  accompanied  by  sensations  which  make 
known  the  time  when  the  act  has  to  be  performed. 
These  sensations  are  in  themselves  not  unpleasant 
at  first,  but  are  accompanied  b}"  a  desire  to  perform 
voluntarily  an  act  which  will  gratify  that  desire. 
Thus,  if  the  breath  be  held  the  desire  to  breathe  is 
not  painful,  but  there  is  a  longing  for  the  sensation 
of  full  inspiration.  So,  in  regard  to  the  call  for 
micturition  and  defecation,  the  sensation  is  one  call- 
ing for  the  gratification  of  a  sense  of  relief.  To 
this  categor}^  belongs  the  desire  for  nourishment, 
liquid  or  solid — the  appetite. 

Appetite  itself  is  a  sensation  so  vague  that  no 
definite  description  of  its  mechanism  can  be  given, 
though  it  is  probably  dependent  on  the  digestive 
glands  in  the  mouth  and  the  stomach.  The  con- 
sciousness of  appetite  is  accompanied  by  increased 
secretion  of  these  glands — so  much  so,  that  even  the 
contemplation  of  a  satisfying  meal  may  cause  the 
"  mouth  to  water."  The  appetite  or  desire  for  food 
may  be  increased  by  the  sight  or  odour  of  tempting 
viands,  or  even  by  the  mental  contemplation  of  them, 
and  an  abundant  flow  of  the  gastric  juices  may 
result  from  such  stimulation. 

The  appearance  of  a  normal  appetite  follows 
the  efficient  absorption  of  food  and  its  ex])enditure 
in  the  production  of  energy.  Thus  it  is  seen  at  its 
best    in    tliose    wlio    work    in    the    open    air.     Tlie 


120  Chapter  XII. 

gratification  of  an  appetite  being  amongst  the  most 
elemental  of  pleasures,  the  presence  of  appetite  is 
a  rough  indication  of  health.  Man's  environment 
so  often  prevents  its  display  that  means  are  taken 
to  excite  an  appetite  by  providing  food  in  a  manner 
that  will  supply  the  craving. 

These  artificial  aids,  used  to  create  appetite, 
diminish  the  value  of  this  sensation  as  a  diagnostic 
aid.  The  loss  of  appetite,  as  seen  in  animals 
(horses,  cattle),  is  the  most  important  sign  of  im- 
paired health,  and  its  return  is  an  indication  of 
restoration  to  health.  In  man  also  it  has  signifi- 
cance, but,  as  man  resorts  to  all  sorts  of  artificial 
aids,  this  significance  is  often  diminished.  Still  the 
question  of  loss  and  return  of  appetite  affords 
valuable  aid  in  diagnosis.  When  an  individual 
loses  his  appetite  it  may  be  taken  as  an  indication 
that  all  is  not  well.  The  loss  of  appetite  maj^,  with 
reasonable  probability,  be  referred  to  a  diminished 
excitability  of  the  secretory  glands  or  their  nerves. 
The  secretory  reflexes  which  are  associated  with 
appetite  may  be  played  upon  in  a  great  variety  of 
ways,  as  by  mental  excitement,  impaired  metabolism 
(as  in  enforced  rest),  increased  temperature  and  the 
agents  inducing  it,  affections  of  the  digestive  tube 
and  other  organs.  The  symptom  of  anorexia,  loss 
of  appetite,  merely  indicates,  therefore,  that  there 
is  something  wrong  in  the  economy.  Further  ex- 
amination may  reveal  the  cause,  and  the  behaviour 
of  the  appetite  may  often  prove  a  safe  guide  as  to 
the  progress  or  retrogression  of  the  ailment. 

Certain  results  follow  the  loss  of  appetite  ;  the 
tongue  becomes  furred,  the  mouth  unpleasant  from 
the  lack  of  the  mechanical  friction  of  the  tongue 


Affections  of  the   Digestive  Organs.  121 

against  the  palate  and  the  absence  of  juices  from 
the  inactive  glands,  abdominal  discomfort  arises 
from  the  accumulation  of  flatus,  and  the  bowels  are 
inactive  from  absence  of  stimulus. 

An  increased  desire  or  craving  for  food  (bouli- 
mia)  may  arise  during  convalescence  from  a  long 
illness,  such  as  typhoid  fever.  The  craving  is 
probably  due  to  the  tissues  losing  the  poisoned  fluids, 
returning  to  their  normal  state,  and  requiring 
suitable  nourishment  of  which  they  were  deprived 
during  the  illness.  An  abnormal  appetite  may  be 
one  of  a  group  of  symptoms,  referable  either  to  the 
nervous  system,  as  in  hysteria,  or  to  conditions  in 
which  there  is  no  sign  of  mental  defect,  as  in  chloro- 
sis, diabetes  mellitus,  intestinal  worms.  Enormous 
quantities  of  food  may  be  taken  by  those  who  are 
thus  affected. 

Craving  for  certain  forms  of  food  is  a  frequent 
sign,  but  there  is  often  a  craving  for  things  that  are 
not  food,  and  that  are  not  digestible.  This  per- 
verted appetite  may  arise  as  a  matter  of  habit,  for 
the  custom  of  eating  earth  (geophagy)  is  prevalent 
among  natives  of  widely  separated  countries.  In 
some  cases  the  earth  may  contain  nutritious  proper- 
ties, but  in  many  cases  it  is  used,  not  for  its  nutritive 
value,  but  merely  for  the  gratification  of  a  perverted 
taste,  or  to  satisfy  the  craving  in  the  absence  of 
proper  food.  Perversion  of  appetite  is  common 
amongst  the  insane,  but  it  is  also  present  as  a 
bad  habit  amongst  others,  as  children,  chlorotic 
females,  pregnant  women,  and  others  who  have  no 
particular  ailment.  The  objects  eaten  or  swallowed 
are  of  the  greatest  variety,  as  chalk,  coal,  earth, 
plaster,  ashes,  pebbles,  etc. 


122  Chapter  XII. 

64.  Hunger. — While  the  anticipation  preceding^ 
the  performance  of  a  periodic  act  may  be  pleasant 
from  the  prospect  of  gratification,  the  undue  delay 
of  performance  results  invariably  in  the  sensation 
becoming  one  of  distress.  Abstinence  from  food 
may  convert  the  sensation  of  appetite  into  one  of 
hunger,  and  hunger  implies  distress,  and  when 
pushed  to  extreme  is  probably  the  most  clamant  of 
all  desires.  Hunger  becomes  more  than  a  mere 
excess  of  appetite.  Appetite  is  probably,  as  already 
stated,  the  outcome  of  the  active  stimulation  of 
certain  digestive  glands,  while  hunger  is  the  craving 
of  the  whole  body  for  nourishment,  and  the  digestive 
tract,  with  its  limited  sensations,  is  the  vehicle  for- 
the  sustenance  of  the  whole  economy.  This  is  seen 
by  the  fact  that  hunger  may  exist  when  the  stomach 
is  full,  the  appetite  gratified,  but  the  food  prevented 
from  reaching  the  tissues  in  consequence  of  an  intes- 
tinal fistula.  Apart  from  hunger  due  to  starvation, 
an  increased  craving  can  be  induced  by  measures 
taken  to  stimulate  the  appetite,  by  cooking,  and  the 
various  means  of  providing  "  tempting  bits,"  and 
this  may  be  carried  so  far  as  to  become  a  perverted 
habit.  Perverted  tastes  may  arise,  however,  from 
custom,  or  as  a  symptom  of  disease. 

65.  Nausea. — The  unpleasant  sensation,  nausea,, 
is -often  associated  with  loss  of  appetite  and  certain 
affections  of  the  stomach.  Though  it  often  comes 
on  at  an  early  stage  in  the  act  of  vomiting,  it  may 
arise  without  vomiting,  just  as  vomiting  may 
occur  without  any  previous  feeling  of  nausea.  It 
is  associated  with  the  digestive  function,  and  its 
appearance  is  accompanied  by  a  stimulation  of  some 
digestive  glands,  as  shown  by  profuse  flow  of  saliva.. 


Affections  of  the    Digestive   Organs.  123 

In  certain  affections  of  the  stomach,  as  in  the  gastric 
catarrh  of  alcohoHcs,  it  is  the  most  distressful 
symptom,  occurring  usually  after  a  long  fast,  as  in 
the  morning  before  food  is  taken.  It  maj^  arise 
suddenly  from  some  reflex  cause,  as  from  a  bad 
odour,  an  offensive  sight,  or  the  appearance  of 
unattractive  food.  In  addition  to  the  disagreeable 
sensation  there  is  often  some  spasmodic  contraction 
of  certain  muscles,  as  the  diaphragm  with  closure  of 
the  glottis,  as  in  the  preliminary  stage  of  vomiting. 
Accompanying  the  nausea  there  is  often  a  feeling 
ilpfjaintness,  the  pulsej^ecomes  soft,  weak,  and  rapid^ 
and  the  face^blanched,  due  in  all  probability  to  the— 
action  of  the  vagus  diminishing  the  force  of  the 
heart  beat,  and  producing  a  vaso-motor  depression. 

66.^outh  and  Fauces. — The  pain  complained 
of  in  affections  of  the  mouth  and  fauces  may  be  local 
or  referred,  or  both.  Local  pain  in  the  mouth  may 
be  present  in  inflammatory  affections  of  the  mucous 
membrane.  In  toothache  it  may  be  felt  not  only  in 
the  affected  tooth,  but  in  neighbouring  teeth,  and  the 
jaw  may  become  painful  and  tender.  The  pain  may 
be  felt  so  severely  in  places  apart  from  the  offending 
tooth  that  it  requires  some  care  to  detect  which  tooth 
is  at  fault.  The  pain  may  be  referred  to  parts  out- 
side the  mouth,  in  the  cheek,  or  in  some  portion  of  the 
head,  and  the  skin  may  become  very  hyperalgesic.  It 
is  necessarv  in  any  case  of  "  neuralgia  "  of  the  face 
and  the  head  to  carefully  examine  the  condition  of 
every  tooth. 

Tlie  fifth  cranial  nerve  is  particularly  liable  to 
stimulation  from  affections  other  than  those  arising 
from  the  mouth,  and  the  presence  of  pain  in  the  dis- 
tribution of  the  fifth  nerve  may  be  due  to  a  variety 


124  Chaj>ter  XII. 

of  causes.  The  most  striking  of  these  conditions  is 
when  there  is  some  distinct  affection  of  the  nerve 
itself  or  the  nerve  ganghon,  in  the  disease  called 
trigeminal  neuralgia  or  tic  douloureux.  Before  the 
full  character  of  this  complaint  is  revealed  in  all  its 
terrible  characteristics,  there  is  a  period  in  which  it 
resembles  so  closely  the  characters  of  a  toothache 
that  at  first  it  is  almost  invariably  mistaken  for  this 
complaint,  and  one  decayed  tooth  after  another  is 
removed.  The  pain  continuing  to  recur,  the  dentist 
next  attacks  the  sound  teeth,  and  not  infrequently 
every  tooth  is  removed,  yet  pain  continues  to  recur  in 
the  edentulous  jaw.  Relief  may  be  found  after  the 
removal  of  one  or  more  teeth,  but,  as  with  the  opera- 
tion for  nerve  stretching,  it  is  but  temporarj^  It  is 
not  possible  in  the  early  stages  to  distinguish  between 
a  case  of  true  tic  and  a  toothache.  In  both  the  pains 
ma}^  recur  at  intervals,  and,  when  there  is  hyperal- 
gesia of  the  skin  of  the  cheek  in  toothache,  the  resem- 
blance between  the  two  conditions  is  very  complete. 
Thus,  stroking  of  the  hair  may  be  exquisitely  pain- 
ful, and  may  bring  on  a  spasm  of  pain.  When  one 
decayed  tooth  after  another  is  removed  with  no  last- 
ing benefit,  then  the  true  nature  of  the  complaint 
may  be  suspected,  but  as  one  is  loth  to  come  to  the 
conclusion  that  the  case  is  one  of  true  tic  douloureux, 
the  teeth  extraction  continues. 

Another  instructive  form  of  pain  occurs  in  cer- 
tain forms  of  angina  pectoris,  where  the  pain  is  not 
onty  present  in  the  chest  and  arms,  but  may  be  felt 
in  the  lower  jaw  and  throat.  The  pain  of  angina 
pectoris  may  even  start  here,  and  be  limited  almost 
entirely  to  this  region.  The  feeling  is  described  as  a 
sense  of  intense  soreness  along  the  lower  jaw,  akin  to 


Affections  of  the    Digestive   Organs.  125 

what  is  felt  in  some  forms  of  toothache.  The  nerves 
supplying  the  fauces,  and  the  voluntary  muscles  en- 
gaged in  swallowing,  may  also  be  Iwpersensitive,  so 
that  the  patient  has  a  good  deal  of  pain  in  swallow- 
ing. In  rare  cases,  after  a  severe  attack  of  angina 
pectoris,  the  patient  ma}^  complain  of  pain  in 
swallowing  for  weeks  after  the  attack  has  passed  off. 
Doubtless,  in  such  cases,  the  violent  stimulation  has 
reached  the  medulla  and  upper  part  of  the  cord  by 
the  vagus,  and  the  stimulation  has  affected  the 
sensory  cells  in  the  neighbourhood  and  left  an 
irritable  focus,  as  witnessed  by  the  hyperalgesia  of 
the  muscles  and  mucous  membrane  shown  in  the 
act  of  swallowing. 

Inflammator}"  affections  in  the  fauces  often 
cause  great  pain  in  the  act  of  swallowing.  When  the 
tonsils  are  acutely  inflamed  the  increased  secretion 
of  mucus  continuously  excites  the  act  of  swallowing 
and  causes  great  distress.  The  pain  is  felt  not  only 
in  the  inflamed  parts,  but  extends  into  the  sides  of 
the  neck,  and  up  into  the  ear.  The  skin  of  the  neck 
behind  the  jaw  may  become  hyperalgesic,  and 
frequently  there  can  be  detected  enlarged  and 
tender  glands  behind  the  jaw. 

A  number  of  patients  may  complain  of  pain  on 
swallowing,  and  when  careful  investigation  is  made 
it  will  be  found  to  be  due  to  a  form  of  infection  very 
common  amongst  those  who  use  false  teeth  where  the 
utmost  cleanliness  is  not  observed.  The  patient  fre- 
quently complains  of  a  sore  throat,  and  if  the  fauces 
be  inspected  a  slight  redness  of  the  pillars  can  be 
detected.  If  the  patient  wears  a  plate  on  the  roof  of 
the  mouth,  and  this  be  removed,  the  underlying 
mucous  membrane  will  be  found  swollen  and  red,  and 


126  Chapter  XII. 

from  this  place  to  the  fauces  there  can  be  detected  an 
extension  of  the  inflammation  in  the  form  of  small 
red  dots.  Sometimes  the  surface  of  the  mucous 
membrane,  under  the  plate,  may  be  covered  with 
patches  of  thrush,  and  an  infective  process  may 
extend  to  the  parotid  and  sub-lingual  glands,  causing 
severe  inflammation  and  swelling  of  these  glands. 
Inspection  of  the  mouth  may  reveal  other  abnor- 
malities, as  ulcers. 

A  very  interesting  instance  of  referred  sensation 
is  seen  in  passing  a  bougie  into  the  eustachian  tube. 
When  a  catheter  is  passed  into  the  eustachian  tube 
for  the  purpose  of  insuflation,  the  sensation  pro- 
duced by  the  catheter  is  referred  to  the  back  of  the 
nose.  If  a  bougie  be  passed  along  the  catheter  into 
the  eustachian  tube,  the  sensation  is  at  first  referred 
to  some  place  between  tiie  back  of  the  nose  and  the 
ear.  If  the  bougie  be  pushed  further  in,  a  part  is 
reached  where  the  sensation  is  suddenly  referred  to 
the  neck  behind  the  jaw.  This  transference  of  the 
sensation  is  doubtless  due  to  the  parts  being  supplied 
by  nerve  fibres  from  different  sources  —  the  exact 
nature  of  the  supply  I  am  unable  to  determine. 

67.  Tongue.  —  In  health  the  tongue  should  be 
evenly  and  steadily  protruded,  moist,  and  of  a 
slightly  translucent  pale  red  colour.  A  tremulous 
tongue  should  lead  to  an  inquiry  into  the  alcoholic 
habits,  and  an  unevenly  protruded  tongue  to  the 
question  of  paralysis. 

The  principal  cause  of  a  furred  tongue  is 
absence  of  friction,  usually  due  to  deficiency  of 
saliva  and  insuflicient  mastication.  Too  much  stress 
has  been  laid  upon  the  supposed  association  of  the 
furred  tongue  with  certain  "  catarrhal "  conditions 


Affections  of  the    Digestive   Organs.  127 

of  the  stomach  and  bowels.  A  person  with  no 
appetite  has  a  furred  tongue  because  he  does  not 
masticate.  A  person  who  bolts  his  food,  or  who 
washes  his  food  into  his  stomach  by  drinking  while 
eating,  or  who  hves  on  "  slops,"  has  a  furred  tongue 
from  the  same  cause.  The  posterior  third  of  the 
tongue  in  some  is  alwa3"S  furred,  and  in  these  it  will  be 
found  that  the  palate  is  high  and  arched,  so  that  the 
tongue  does  not  come  into  contact  with  the  roof  of 
the  mouth.  ]\Iouth  breathers  also  have  a  tendenc}^  to 
a  furred  tongue,  for  the  playing  backwards  and 
forwards  of  the  air  over  the  tongue  dries  it,  and 
favours  the  formation  of  the  fur.  This  is  especially 
the  case  in  fevers  where  the  hot  air  passing  over  the 
tongue  dries  it.  This  tendency  is  further  increased 
by  the  absence  of  mastication — the  patient  being  so 
often  fed  on  slops.  In  fever  a  fur  ma}^  appear 
in  spite  of  all  precautions.  A  very  striking 
prognostic  sign  may  be  found  in  carefully  watching 
the  tongue  in  febrile  states,  for  the  ea,rliest 
symptom  that  the  fever  is  about  to  jdeld  may 
be  the  appearance  of  a  small  clean  spot  on  the 
tongue. 

68.  Swallowing. — The  act  of  swallowing,  so  far 
as  it  is  carried  out  within  the  region  of  distribution 
of  cerebro-spinal  nerves,  is  a  voluntary  and  conscious 
act ;  but  as  soon  as  the  bolus  passes  beyond  into  the 
region  supplied  by  the  autonomic  nervous  system,  it 
becomes  involuntar}"  and  unconscious.  During  the 
act  the  respiration  is  inhibited  and  the  levator  palati 
raises  the  palate  and  shuts  off  the  nasal  cavities. 
Bilateral  paralysis  of  this  muscle,  as  after  diph- 
theria, leads  to  fluids  regurgitating  down  the  nose 
during  the  act  of  swallowing. 


128  Chapte7-  XII. 

Pain  accompanying  the  act  of  swallowing  is  due 
most  frequently  to  some  inflammatory  infection  of 
the  tonsils  or  fauces.  It  is  generally  referred  to  the 
neck  behind  the  jaw,  or  up  into  the  ear.  Inspection 
of  the  fauces  will  generally  reveal  the  cause.  In 
rare  cases,  as  already  cited,  there  may  be  a  hyperal- 
gesia of  the  mucous  membrane  and  of  the  muscles 
with  a  good  deal  of  pain  on  swallowing. 

There  is  sometimes  shown  a  curious  relationship 
between  the  tonsils  and  the  nerve  supply  of  the 
external  ear.  In  a  number  of  cases  I  have  found 
during  a  tonsilitis  an  attack  of  herpes  zoster  occur, 
the  eruption  appearing  on  the  lobe  and  pinna  of  the 
ear.  This  has  occurred  so  frequenth^  that  the  asso- 
ciation is  more  than  casual,  and  I  suspect  some 
intimate  central  relationship  between  the  nerve 
supply  of  these  parts.  Herpes  zoster  has  been  shown 
by  Head  and  Campbell  to  be  due  to  a  destructive 
inflammation  of  the  ganglia  of  the  sensory  root,  and 
it  is  difficult  to  explain  the  definite  relationship  of 
the  tonsilitis  and  the  herpes  on  the  ear,  but  the  fact 
is  one  worthy  of  consideration  in  the  investigation  of 
the  relationship  of  the  viscera  to  the  cerebro-spinal 
nerves. 

69.  The  (Esophagus.^ — The  nerve  supply  of  the 
oesophagus  being  derived  entirely  from  the  autonomic 
system,  we  get  no  direct  response  to  stimulation.  Pain 
arises  rather  easily  from  stimulation,  especially,  as 
everyone  has  experienced,  on  the  drinking  of  hot 
fluids.  The  pain  thus  excited  is  referred  distinctly 
to  the  front  of  the  chest,  and  although  the  heart  and 
lungs  are  interposed  between  the  site  of  pain 
and  the  oesophagus,  and  although  the  oesophagus 
itself   is   nearer   the   back   of   the   chest   than    the 


Affections  of  the    Digestive   Organs.  129 

front,  everyone  unhesitatingly  refers  the  pain  as 
being  felt  in  the  oesophagus.  Nevertheless,  after  a 
good  many  observations,  I  have  come  to  the  concki- 
sion  that  the  laws  governing  the  sensibihty  of  the 
oesophagus  are  the  same  as  those  governing  the 
sensibihty  of  the  other  portions  of  the  digestive  tube, 
and  that  the  oesophageal  pain  is  a  referred  pain  and 
not  direct.  That  its  sensibiht}^  is  different  from  that 
of  the  stomach  is,  I  think,  undoubted.  The  pain  in 
swallowing  hot  fluids,  for  instance,  is  more  readily 
induced  bv  the  oesophagus  than  by  the  stomach. 
Also  the  stomach  contents,  though  giving  rise  to  no 
sensation  when  in  the  stomach,  may  cause  great 
discomfort  when  the}^  regurgitate  into  the  oesophagus, 
and  it  is  for  this  reason  that  I  assign  the  disagreeable 
sensation  of  heart-burn  to  the  acrid  stomach  contents 
escaping  into  the  oesophagus  {see  p.  141). 

Some  recent  observations  by  Hirst,  Cook  and 
Schlesinger  lead  them  to  the  conclusion  that  the 
sensation  of  heat  and  cold  on  swallowing  fluids  is 
actually  felt  at  the  lower  end  of  the  oesophagus,  but 
their  observations  do  not  disprove,  as  they  seem  to 
think,  the  referred  character  of  the  sensation.  The 
view  I  hold  that  the  sensations  of  heat  and  cold  are 
really  due  to  a  reflex  stimulation  of  the  peripheral 
vaso-motor  nerves  is  not  disproved  because  in  some 
cases  the  sensation  is  felt  "  deeper  "  than  the  skin  ; 
and,  although  I  am  far  from  asserting  that  the  hy- 
])othesis  I  put  forward  is  absolutely  correct,  the 
matter  is  not  the  simple  one  these  observers  seem  to 
i  magine. 

In  some  cases,  particularly  in  females  of  a 
neurotic  habit,  the  moment  a  hard  piece  of  food,  as 
a  small  crust  of  bread,  or  even  a  soft  bolus  or  fluid, 

K 


130  Chapter  XII. 

touches  the  upper  part  of  the  oesophagus,  the 
oesophagus  at  once  contracts  with  such  violence  and 
persistence  that  no  food  can  be  taken  for  some  time. 
Sometimes  a  small  portion  of  food  may  be  grasped 
in  the  spasm,  when  the  spasm  may  last  for  hours, 
and  the  patient  be  in  great  suffering  on  account  of 
the  difhculty  in  breathing  and  the  excessive  flow  of 
saliva  that  cannot  be  swallowed.  The  forcible  pas- 
sage of  a  bougie  or  probang  at  once  gives  relief.  In 
a  large  number  of  cases  I  have  found  the  systematic 
passage  of  a  bougie  the  best  means  of  treatment.  In 
some  rare  cases  the  seat  of  the  spasm  may  be  lower 
down. 

In  stricture  of  the  oesophagus,  if  the  stricture 
be  high  up  the  food  is  rejected  at  once,  if  low  down 
it  may  be  delayed  for  some  time.  Sometimes  the 
oesophagus  wall  contracts  strongly,  and,  as  in 
obstruction  of  the  bowel,  pain  may  arise  from  the 
peristalsis,  and  is  always  referred  to  the  front  of 
the  chest,  at  a  level  near  that  of  the  stricture.  Great 
care  should  be  taken  in  all  cases  in  the  passage  of 
an  exploratory  bougie,  lest  injury  be  done  to  the 
walls. 


(     131     ) 


Chapter    XIII. 

AFFECTIONS   OF  THE   DIGESTIVE   ORGANS. 
THE    STOMACH. 

70.  The    Nature  of  the  Symptoms. 

71.  The  Nerve  Supply  of  the  Stomach. 

72.  The  Site  of  Pain  in  Affections  of  the  Stomach. 

73.  The  Character  of  the  Pain. 

74.  Hyperalgesia. 

75.  Superficial  Reflexes. 

76.  Viscero-motor  Reflexes. 

77.  Vomiting. 

78.  Pyrosis  and   Heart-hum. 

79.  Air  Suction. 

80.  Functional  Symptoms. 

81.  Structural  Symptoms. 

82.  The   Diagnosis  of  Stomach   Affections. 

83.  Pain  in   Gastric    Ulcer. 

70.  The    Nature    of    the     Symptoms.  —  The 

stomach  being  an  organ  that  daily  makes  itself 
known  by  sensations  of  pleasure  or  discomfort,  forces 
its  symptoms  upon  all.  Considering  its  highly  com- 
plex organisation  it  is  a  wonderfully  long-suffering 
organ,  for  it  not  only  digests  food  suitable  for  the 
whole  organism,  but  it  has  to  submit  to  improper 
food,  to  the  gratification  of  gluttonous  desires,  and 
to  the  caprices  of  perverted  tastes.     It  cannot  be 


132  Chapter  XIII. 

wondered  at  that  it  should  so  often  become  deranged 
in  structure  and  function,  and  that  these  derange- 
ments should  be  of  various  kinds. 

Its  accessibility  has  permitted  many  observa- 
tions to  be  made  on  its  functions  in  health  and 
disease,  and  has  afforded  scope  for  the  ingenuity  of 
the  physiologist,  the  chemist,  and  the  clinician. 
Although  continual  progress  is  being  made  in  the 
discovery  of  its  properties,  it  must  be  admitted  that 
little  of  practical  importance  has  been  evolved  for 
the  purpose  of  diagnosis  and  treatment  of  the  great 
majority  of  patients.  So  far  as  the  physiologist  is 
concerned  he  cannot  acquire  the  necessary  infoima- 
tion,  because  symptoms  of  disordered  digestion  are 
usually  the  outcome  of  years  of  improper  feeding. 
Food  unsuitable  for  the  digestive  powers  of  the 
stomach  deranges  the  functions  of  its  secretory 
glands  and  the  structures  of  its  walls,  and  it  must  be 
confessed,  we  are  ignorant  of  the  nature  of  these 
clianges.  It  is  for  this  reason  that  so  little  advance 
has  been  made  in  diagnosis  and  treatment,  apart 
from  the  progress  of  surgical  methods,  and  of  the 
examination  of  the  stomach  contents.  Some  light 
may  be  thrown  on  obscure  diseases  by  the  observation 
of  the  progress  through  the  alimentary  canal  of  a 
bismuth  meal  by  the  X-rays.  These  methods,  how- 
ever, are  applicable  to  but  a  very  small  proportion 
of  sufferers  from  stomach  affections. 

Attempts  are  continually  being  made  to  classify 
affections  of  the  stomach,  and  the  lack  of  agreement 
in  these  classifications  is  merely  due  to  the  fact  that 
attempts  are  made  to  differentiate  what  cannot  be 
differentiated.  This  will  be  realised  when  the  nature 
of  stomach  symptoms  is  considered.     Apart  from 


The  Stomach.  133 

some  characteristic  vomits  (blood,  mucus),  and  cer- 
tain changes  indicated  in  the  position  of  the  organ 
(and  these  refer  only  to  a  very  small  proportion  of  the 
cases),  all  the  symptoms  are  of  a  reflex  nature,  pain, 
cutaneous  and  muscular  hyperalgesia,  muscular  con- 
traction, vomiting,  air  suction.  As  any  adequate 
stimulus  may  suffice  to  produce  these  symptoms,  and 
as  this  adequate  stimulus  ma}^  arise  from  the  most 
varied  causes,  trivial  or  severe,  it  follows  that  there 
is  a  great  similarity  in  the  symptoms  in  diseases  of 
the  most  varied  kinds.  Hence  it  is  impossible  in 
many  cases  to  tell  the  nature  of  the  affection  ;  for 
instance,  a  passing  simple  "  incUgestion "  arising 
from  one  indiscreet  meal  may  present  the  s^miptoms 
of  "  gastritis  "  or  ulceration.  For  this  reason  it  often 
happens  that  no  satisfactory  diagnosis  can  be  made 
in  the  early  stages  of  a  chronic  stomach  complaint. 
To  ascertain  the  true  nature  of  many  stomach  affec- 
tions it  is  necessary  to  wait  and  observe  the  results 
of  treatment  and  the  progress  of  the  disease.  When 
patients  come  in  a  late  stage  of  the  complaint  the 
peculiar  features  of  any  given  disease  may  have 
become  so  evident  that  an  accurate  diagnosis  can  be 
made  ;  but  these  form  but  a  small  proportion  of  the 
chronic  cases  that  the  practitioner  has  to  treat. 

I  have  already  pointed  out  that  in  visceral 
disease  certain  areas  in  the  spinal  cord  may  become 
for  a  time  so  irritable  that  stimuli  from  the  peri- 
phery give  rise  to  an  exaggerated  response,  as  when 
the  skin  becomes  hyperalgesic  and  the  recti  muscles 
contracted.  This  irritable  focus  in  the  cord  is  of 
great  frequency  in  stomach  affections.  Not  only  does 
slight  stimulation  of  the  skin  produce  pain,  but  a 
stimulus    reaching    the    irritable    focus    from    any 


134  Chapter  XIII. 

source  may  produce  pain,  and  it  is  for  this  reason 
that  the  ingestion  of  food  is  so  frequentl}?'  accom- 
panied by  pain.  When  pain  occurs  after  food  it 
must  not  be  assumed  that  there  is  an  inflammation 
of  the  mucous  membrane,  or  that  the  stomach  is  itself 
hypersensitive.  The  ingestion  of  food  under  normal 
circumstances  is  accompanied  by  reflex  processes 
which  are  not  perceived,  and  pain  merely  indicates 
that  there  is  an  irritable  focus  in  the  cord  through 
which  these  reflex  processes  pass.  The  lesion  induc- 
ing the  irritable  focus  in  the  cord  may  not  neces- 
sarily be  a  stomach  lesion  at  all,  but  may  arise  from 
a  neighbouring  organ  whose  reflex  centre  in  the 
spinal  cord  is  in  close  proximity  to  that  of  the 
stomach.  In  gall-stone  colic  the  pain  may  be  so 
violent  as  to  invade  the  stomach  area  in  the  cord, 
and  an  illustration  of  the  pain  arising  on  the  ingestion 
of  food  in  a  case  of  hyperalgesia  due  to  gall-stone 
disease  is  given  on  page  90. 

In  true  lesions  of  the  stomach  this  irritable 
focus  in  the  cord  is  readily  produced,  and  its  presence 
is  demonstrated  by  the  ease  with  which  pain  is  in- 
duced in  certain  stages  of  digestion  by  the  hyperal- 
gesia of  the  skin  and  muscles  of  the  epigastrium,  and 
by   the  hardened  epigastric   muscles. 

71.  The  Nerve  Supply  of  the  Stomach. — The 
stomach  is  supplied  by  nerves  from  the  dorsal  sym- 
pathetic and  from  the  vagus.  The  origin  of  the 
s^^mpathetic  has  not  been  exactly  determined,  as  the 
experimental  attempts  to  find  the  efferent  fibres  that 
supply  the  stomach  have  not  been  very  successful,  so 
that  the  place  of  origin  in  the  spinal  cord  is  best 
inferred  from  clinical  observations  of  the  area  in 
which  the  pain  and  hyperalgesia  arise. 


The  Stomach.  135 

The  epigastric  region  is  essentiall}'  the  place  to 
which  the  sensory  symptoms  are  referred,  and  it  is 
tlie  upper  part  of  the  left  rectus  muscle  which  con- 
tracts first  in  response  to  stim.ulation  from  the 
stomach.  The  nerve  supply  to  the  skin  of  this  region 
comes  from  the  sixth  and  seventh  thoracic  nerves, 
and  the  upper  portion  of  the  rectus  is  supphed  by 
the  sixth.  When  the  pain  is  severe,  and  tends  to 
radiate,  it  generally  goes  to  the  left  of  the  epigas- 
trium, but  may  invade  the  regions  of  the  front  of 
the  chest  supplied  by  the  fifth  and  fourth  thoracic 
nerves.  I  have  seen  the  symptoms  in  rare  cases 
resemble  attacks  of  angina  pectoris,  and  it  has 
seemed  to  me  that  the  cause  of  the  pain  in  such  cases 
was  violent  peristalsis  of  the  cardiac  end  of  the 
stomach. 

The  burning  pain  of  heart-burn  is  generall}^  felt 
over  the  lower  part  of  the  sternum,  in  the  region  of 
distribution  of  the  fifth  thoracic  nerve  in  the  chest. 
It  has  seemed  to  me  that  the  immediate  cause  of  this 
pain  is  the  regurgitation  into  the  oesophagus  of  the 
acrid  contents  of  the  stomach.  The  frequency'  with 
which  in  these  cases  some  of  the  stomach  contents 
regurgitate   into   the   mouth   confirms  this   view. 

The  result  of  vagus  stimulation  is  difficult  to 
determine  in  stomach  cases.  Pain  may  be  felt  in  the 
neck  and  jaw  in  severe  gastric  colic,  very  like  that 
felt  in  some  cases  of  angina  pectoris,  and  this,  I  can 
only  conclude,  is  a  stimulus  reaching  the  fifth  cranial 
and  upper  cervical  nerve  centres,  by  means  of  the 
vagus.  The  brow  pain  felt  in  swallowing  ice  is 
often  spoken  of  as  a  vagal  reflex,  but  this  pain  arises 
not  from  the  stomach,  but  from  the  back  of  the 
mouth.    This  can  be  demonstrated,  in  suitable  cases, 


136  Chapter  XIII. 

by  keeping  the  ice  against  the  soft  palate,  when  the 
pain  will  be  evoked.  The  same  peculiar  pain  can  also 
be  evoked  by  immersing  the  scalp  in  cold  water. 

In  rare  cases  vagal  stimulation,  excited  by 
swallowing  or  by  the  ingestion  of  food  into  the 
stomach,  can  produce  irregular  action  of  the  heart, 
of  the  nature  of  heart-block,  or  of  extra-systoles. 

72.  The  Site  of  the  Pain  in  Affections  of  the 
Stomach. — In  1892  I  published  a  paper,  in  which  I 
gave  the  results  of  a  careful  inquiry  into  the  site  of 
pain  in  320  cases  of  affections  of  the  stomach.  In 
the  analysis  I  found  that  95  per  cent,  referred  their 
pain  to  the  epigastrium.  Since  that  time  I  have  kept 
records  of  some  thousands  of  cases,  with  the  same 
results.  Whatever  the  nature  of  the  lesion  the  pain 
is  referred  with  great  certainty  to  the  epigastrium 
(B.  Fig.  8,  page  117).  It  may  radiate  from  here  up 
into  the  chest,  or  to  the  left.  It  is  not  infrequently 
accompanied  by  a  pain  in  the  back,  and  the  patient 
sometimes  states  that  the  pain  strikes  from  the  front 
through  to  the  back.  It  might  be  inferred  from  the 
situation  of  the  pain  that  the  pain  itself  was  actually 
in  the  stomach,  but  one  can  demonstrate  that  it  is 
really  referred  to  the  peripheral  distribution  of  the 
cerebro-spinal  nerves  in  the  abdominal  walls.  Thus, 
in  many  cases,  the  skin  and  muscles  in  the  area  in 
which  the  pain  is  felt  are  hyperalgesic,  and  it  is  but 
reasonable  to  infer  that  the  pain  felt  by  the  patient 
is  referred  to  a  region  where  the  sensory  nerves  are 
so  demonstrably  affected.  The  movements  of  the 
stomach  do  not  cause  a  displacement  of  the  pain, 
and  when  the  stomach  itself  is  shifted,  as  by  deep 
inspiration  and  expiration,  there  is  no  accompany- 
ing shifting  of  the  pain.   In  localised  affections  of  the 


The  Stomach.  137 

«tomach  (as  ulcer),  however  varied  the  situation  may 
be  from  cardiac  to  pyloric  end,  the  pain  in  tlie  great 
majority  of  cases  is  referred  by  the  patient  to  some 
part  of  the  epigastric  region  {see  p.  148). 

73.  The  Character  of  the  Pain  and  its 
Relation  to  the  Ingestion  of  Food. — Although  the 
stomach  is  a  hollow  muscular  viscus,  severe  cramp- 
like pain  from  violent  peristalsis  is  of  rare  occur- 
rence. It  will  usually  be  found,  in  the  long  run, 
that  the  so-called  "  cramp  of  the  stomach,"  in  which 
there  is  pain  of  great  severity  referred  to  the 
epigastrium,  is  due  to  gall-stone  colic.  I  have 
watched  many  patients  for  years  who  suffered  from 
these  severe  attacks,  and  found  that  they  all  turned 
out  to  be  cases  of  gall-stone  disease.  In  later  years 
I  have  had  little  difficulty  in  recognising  their 
origin,  because  of  the  peculiar  distribution  of  the 
reflex  phenomena  in  gall-stone  disease  {see  p.  159). 
Violent  cramp-like  pain  may  rarely  arise  in  stomach 
affections,  but  the  pain  tends  to  radiate  higher  into 
the  chest,  and,  ma}^  be,  into  the  Jaw  (vagus  stimula- 
tion). More  frequently  the  pain  of  stomach 
affections  is  of  a  dull  prolonged  boring  character. 
Its  position  being  so  definitely  situated  in  a  region 
remote  from  the  seat  of  the  lesion  (as  in  gastric 
ulcer)  shows  that  it  is  the  outcome  of  a  stimulation 
of  an  irritable  focus  in  the  spinal  cord.  The  pain 
is  therefore  more  prolonged,  and  varies  little  in  in- 
tensity. Such  a  distinction  of  the  character  of  the 
pain  can  usually  be  made,  and  seems  to  account  for 
the  persistent  boring  pains  in  gastric  ulcer  and  in 
other  conditions. 

Tlie  relation  of  tlie  pain  to  the  ingestion  of  food 
is  verv  variable.     In  some  the  introduction  of  food 


138  Chapter  XIII. 

into  the  stomach  causes  immediate  pain,  or  the  pain 
may  come  on  at  variable  intervals  after  food.  When 
it  comes  on  two  or  three  hours  after  food,  relief 
may  sometimes  be  obtained  from  taking  more  food. 
No  very  certain  conclusions  can  be  drawn  from  this 
relation  of  pain  to  the  ingestion  of  food.  Attempts 
have  been  made  to  diagnose  the  position  of  an  ulcer 
from  this  relationship,  but  there  is  no  ground  for 
such  a  deduction.  As  a  matter  of  experience  the 
pain  in  gastric  ulcer  may  come  on  at  any  period 
whatever  its  situation.  This  will  be  appreciated 
when  it  is  recognised  that  the  ingestion  of  food  or 
some  stage  of  its  digestion  acts  as  a  stimulant  to  an 
irritable  focus  in  the  spinal  cord  {see  page  87).  The 
occurrence  of  the  pain  one  or  two  hours  after  the 
food,  with  symptoms  of  peristalsis  (as  recognised 
by  the  wavy  character  of  the  pain)  and  with  acrid 
regurgitations  into  the  oesophagus,  is  fairly  charac- 
teristic of  one  form  of  dyspepsia,  sometimes  spoken 
of  as  "hyperchlorhydria,"  in  which  the  trouble  is  sup- 
posed to  be  due  to  an  excessive  secretion  of  hydro- 
chloric acid.  This  form  of  indigestion  often  j'ields 
readily  to  suitable  treatment,  but  it  is  not  infre- 
quently associated  with  gastric  ulcer  and  gall-stone 
disease,  and  this  association  should  be  kept  in  mind» 

74.  Hyperalgesia. — In  addition  to  the  pain  other 
sensory  phenomena  may  arise,  the  chief  of  which  is 
hyperalgesia  of  the  skin  and  deeper  structures.  The 
area  which  becomes  hyperalgesic  is  the  epigastric. 
It  may  be  limited  to  a  small  area  in  the  middle,  but 
it  is  usuall}'  diffuse  with  indefinite  borders,  extending 
sometimes  as  an  irregular  band  round  the  left  side 
to  the  spine. 

The  h3^peralgesia  may  not  be  present  in  the 
skin,  but  in  the  muscles,  or  in  the  sensitive  layer 


The  Stomach.  139 

outside  the  peritoneum.  This  can  be  shown  by  first 
testing  the  skin  and  finding  the  sensibiUt}^  normal, 
then  pressing  so  that  the  muscle  is  stimulated  ;  or 
by  pushing  the  finger  between  the  recti  when  the 
peritoneal  layer  may  be  found  sensitive.  Of  course, 
in  the  latter  case,  one  cannot  assert  that  the  pain  is 
elicited  from  this  layer  alone,  for  the  pressure  may 
affect  other  structures,  but  in  view  of  the  observa- 
tions of  Ramstrom  this  conclusion  is  justifiable  {see 
page  35). 

75.  Superficial  Reflexes. — Associated  with  this 
hyperalgesia  there  is  invariably  an  increase  of  the 
reflexes,  superficial  and  viscero-motor.  The  super- 
ficial is  demonstrated  by  the  liveHness  of  the  response 
when  the  skin  is  stimulated,  the  upper  part  of  the 
right  rectus  contracting  rapidly  and  powerfully.  Not 
only  is  the  increased  reflex  activit}^  shown  in  the 
response  to  the  stimulation  of  the  skin  in  the  epigas- 
trium, but  it  is  also  shown  by  the  greatly  extended 
cutaneous  field  from  which  it  can  be  elicited.  Nor- 
mally the  reflex  of  the  upper  portion  of  the  rectus 
muscle  is  obtained  from  an  area  limited  to  the  epi- 
gastrium, but  with  an  ii'ritable  focus  in  the  cord  the 
cutaneous  area,  stimulation  of  which  will  cause  a 
reflex  contraction  of  the  upper  portion  of  the  rectus, 
may  extend  as  high  as  the  axilla.  The  extension  of 
this  area  follows  some  peculiar  law,  as  responses 
cannot  be  elicited  from  the  whole  of  the  left  chest, 
but  only  from  an  area  extending  in  an  irregularly 
shaped  hand  up  the  side  to  the  axilla. 

76.  Viscero-motor  Reflexes.  —  Tlie  viscero- 
motor reflex  is  recognised  by  a  permanent  rigidity 
of  the  upper  division  of  the  left  rectus  muscle.  Tliis 
ma>'  be  so  slio;ht  as  to  be  evidcMit  as  an  increase  in  the 


140  Chapter  XIII. 

tone  of  the  muscle  and  detected  onl}^  on  comparison 
with  the  other  parts  of  the  muscular  wall  of  the 
abdomen,  or  it  may  be  hard  and  resistant.  In  seek- 
ing for  this  reflex  gentle  exploration  is  needed  to 
avoid  the  production  of  the  superficial  reflex. 

77.  Vomiting.  —  Vomiting  as  a  S3^mptom  of 
stomach  affection  is  somewhat  infrequent  and  of  very 
variable  significance,  and  the  most  persistent  vomit- 
ing may  arise  reflexly  from  other  organs,  as  in  the 
persistent  vomiting  of  catarrhal  jaundice,  preg- 
nancy and  brain  affections.  As  a  symptom  of  stomach 
affections  the  frequency  of  the  vomiting  and  the 
nature  of  the  material  vomited  constitute  the  best 
evidence.  An  occasional  attack  of  vomiting  may 
arise  from  a  great  many  causes.  In  persistent  vomit- 
ing, if  reflex  vomiting  from  other  organs  can  be 
excluded,  some  inflammatory  affection  maj^  be  recog- 
nised, and  the  possibility  of  gastric  ulcer  considered. 
The  response  to  treatment  is  an  important  factor  in 
diagnosis. 

Certain  characteristics  at  the  time  of  vomiting 
give  information.  The  morning  sickness  of  preg- 
nancy and  of  the  alcoholic  is  very  characteristic.  The 
vomiting,  once  a  day,  or  every  day  or  two,  of  large 
quantities  is  suggestive  of  the  dilated  stomach 
secondary  to  pyloric  stenosis.  The  character  of  the 
material  vomited  is  also  of  importance.  If  the  con- 
tents of  the  stomach  contain  the  food  that  has  been 
taken  many  hours  before,  some  obstruction  to  its 
passage  is  suggested.  The  thick  viscid  mucus 
vomited  is  characteristic  of  a  somewhat  violent 
gastritis.  The  presence  of  blood  (coffee-ground 
vomit)  is  characteristic  of  ulceration.  Inquiries 
should  always  be  made  for  the  presence  of  "  tarry  " 


The  Stomach.  141 

stools.  The  vomiting  of  large  quantities,  sometimes 
with  brown  froth,  is  characteristic  of  dilatation  of 
the  stomach.  Vomiting  with  a  faecal  odour  usually 
indicates  obstruction  of  the  bowel.  The  absence  of 
hydrochloric  acid  in  the  vomit  suggests  the  possi- 
biUty  of  cancer. 

78.  Pyrosis  and  Heart-burn. — The  food  may 
regurgitate  back  into  the  oesophagus.  Sometimes 
this  is  normal  (merycism),  and  is  of  the  nature  of  the 
return  of  the  cud  in  ruminants.  In  certain  cases, 
when  the  stomach  contents  become  abnormally  sour 
and  acrid,  strong  peristalsis  may  produce  pain  with 
regurgitation  of  some  of  the  contents  into  the 
oesophagus,  and  thus  give  rise  to  the  painful  burning 
sensation  described  as  "  heart-burn."  This  vadjy  be 
accompanied  by  the  return  into  the  mouth  of  some 
of  the  contents  of  the  stomach,  sometimes  insipid  to 
the  taste,  sometimes  sour  and  acrid  (pj^'rosis,  water- 
brasli).  One  form  of  this  condition  has  received  the 
name  of  hyperchlorhydria,  because  an  excess  of 
hydrochloric  acid  is  present  in  the  stomach  contents, 
and  because  it  can  be  relieved  by  alkalies.  But  this 
increase  in  hydrochloric  acid  is  but  one  of  the 
abnormal  manifestations,  and  excess  in  its  secretion 
is  not  necessarily  the  disease,  nor  the  cause  of  tlie 
symptoms,  for  the  administration  of  hydrochloric 
acid  reheves  the  symptoms,  and  the  presence  of 
hydrocliloric  acid  in  the  oesophagus  does  not  cause 
h(nirt-burn.  There  are  other  acrid  substances  of 
unknown  nature  present  which  evidently  excite  the 
peristalsis  of  the  stomach. 

79.  Air  Suction.  -Flatulence  is  a  common  com- 
plaint with  dyspeptics,  but  true  flatulence,  i.e., 
flatulence  due  to  evolution  of  gases  in  the  stomach, 


142  Chapter  XIII. 

is  relatively  rare.  The  vast  number  of  people  who 
suffer  from  "  attacks  of  wind,"  and  who  appear  to 
expel  large  quantities  with  a  loud  noise,  owe  their 
attacks  to  air  spasmodically  sucked  into  the  oesopha- 
gus or  into  the  stomach.  These  may  start  with  a 
slight  feeling  of  distension  after  meals,  when  the 
patient  endeavours  to  obtain  relief  by  expelling 
wind.  In  this  attempt  air  is  unconsciously  sucked 
into  the  oesophagus,  and  its  noisy  expulsion  is  sup- 
posed to  be  an  evidence  of  air  being  expelled  from 
the  stomach.  Som.etimes  the  air  is  sucked  into  the 
stomach,  and  its  expulsion  is  accompanied  by  some 
flatulence  that  was  present  in  the  stomach,  and  in 
consequence  considerable  relief  is  obtained.  Some 
people  when  suffering  from  pain  get  a  measure  of 
relief  by  sucking  air  voluntarily  into  the  stomach 
and  then  expelling  it. 

This  air  suction  occurs  most  frequently  in 
people  of  a  neurotic  temperament,  and  the  attacks 
may  come  on  when  they  are  put  out,  worried,  or 
suffering  from  affections  of  other  organs.  When  a 
patient  complains  of  attacks  of  flatulence  coming  on 
suddenly  as  during  sleep,  it  will  often  be  found  that 
the  patient  is  an  air-sucker.  It  might  seem  that  an 
uncontrollable  reflex  would  cause  the  air  suction,  for 
patients  during  an  attack  of  angina  pectoris  may 
hold  themselves  in  such  a  manner  that  air  is  uncon- 
sciously sucked  in,  and  its  expulsion  is  often  accom- 
panied by  such  relief  that  the  origin  of  the  suffering 
is  put  down  to  a  stomach  affection.  Attacks  of 
air  suction  may  be  stopped  at  once  by  the  mouth 
being  kept  wide  open  by  a  gag.  Willie's  article  in 
the  Edinburgh  Hospital  Reports  (Vol.  I.)  throws  a 
great  deal  of  light  on  the  subject. 


The  Stomach.  143 

/  80.  Functional  Symptoms.  —  The  symptoms 
that  arise  from  changes  in  function  are  available  in 
relatively  few  cases.  Those  clue  to  alteration  in  the 
secretion  are  mainly  limited  to  the  recognition  of  an 
excess  of  mucus,  or  an  increase  or  diminution  of  the 
amount  of  free  hydrochloric  acid  in  the  stomach 
contents,  obtained  either  from  the  vomit  or  by  the 
stomach  tube.  There  are  so  man}^  individual  varia- 
tions in  the  amount  of  gastric  juice  secreted  and  in 
the  relative  proportion  of  hydrochloric  acid  present, 
that  deductions  drawn  from  an  examination  of  the 
stomach  contents  must  be  applied  with  the  greatest 
caution. 

Increase  in  the  amount  of  hydrochloric  acid  is 
indicative  of  no  definite  lesion,  and  the  absence  of 
free  hydrochloric  acid,  though  suggesting  the  possi- 
bility of  cancer,  is  by  no  means  diagnostic,  as  it  may 
be  absent  in  a  variety  of  conditions.  Save  that  its 
absence  necessitates  the  consideration  of  the  question 
of  cancer,  it  is  doubtful  if  the  symptom  is  of  any 
special  importance.  Functional  derangement  of  the 
digestive  fluid  may  be  detected  by  the  delay  of 
digestion.  This  delay  is  recognised  by  the  retention 
by  the  stomach  of  portions  of  undigested  food,  and 
by  observing  the  time  taken  to  digest  a  test  meal, 
and  by  the  observation  of  the  passage  of  a  bismuth 
meal  through  the  stomach  by  the  X-rays. 

Dilatation  of  the  stomach  is  an  evidence  of  a 
loss  of  the  function  of  tonicity  in  the  muscular  wall, 
and  can  be  detected  by  careful  percussion,  or  by  the 
presence  of  splashing  when  the  stomach  is  shaken  by 
succussion,  or  by  tapping  over  the  stomach.  The 
extent  of  the  dilatation  can  often  be  made  out  by 
distending  the  stomach  witli  carbonic  acid  gas.     The 


144  Chapter  XIII. 

simplest  method  is  to  give  the  acid  part  of  a  seidlitz 
powder  in  solution  first,  followed  by  the  alkaline. 
The  evolution  of  the  carbonic  acid  gas  causes  a 
visible  swelling  in  the  abdomen  due  to  the  distension 
of  the  stomach. 

The  use  of  the  X-rays  in  the  examination  of  th& 
digestive  tract  has  been  of  the  greatest  service.  By 
giving  a  meal  containing  a  large  quantity  of  bismuth 
the  movements  of  the  food  can  be  detected.  Obser- 
vation by  this  means  has  shed  an  unexpected  light 
upon  the  position  and  shape  of  the  normal  stomach, 
and  shows  that  the  description  usually  given  is  quite 
wrong.  In  quite  healthy  people  the  stomach  may 
be  as  low  as  the  um.bilicus.  In  fact  so  variable  is 
the  shape  and  position  of  the  stomach  in  presumably 
healthy  people  that  no  certain  standard  is  yet 
recognised.  In  consequence  of  this  the  recognition 
of  abnormal  conditions  of  the  stomach  by  the  X-rays 
is  mostly  limited  to  cases  of  very  great  increase  in 
size. 

The  retention  of  portions  of  food  in  the  stomach 
for  a  considerable  time  affords  evidence  of  the 
inefficiency  of  the  peristaltic  contractions  to  empty 
the  stomach  of  its  contents.  Although  dilatation  is 
seen  in  its  most  characteristic  form  in  emaciated 
people  with  pyloric  stenosis,  yet  it  may  be  of  con- 
siderable extent  where  there  is  no  obstruction  ;  and 
there  may  be  difficulty  in  deciding  whether  the 
dilatation  is  secondary  to  the  pyloric  stenosis.  A 
long  history  of  stomach  trouble  with  pain,  particu- 
larly if  referred  to  the  lower  part  of  the  epigastrium, 
suggests  pyloric  stenosis.  In  rare  cases  a  history  of 
vomiting  blood,  or  of  huge  liquid  vomits  at  intervals, 
is  also  suggestive  of  pyloric  stenosis.     Apart  from 


The  Stomach.  145 

pyloric  stenosis  dilatation  of  the  stomach  is  a  very 
common  condition,  and  may  be  present  when  there 
is  no  symptom  pointing  to  digestive  insufficiency. 
At  other  times  dilatation  may  be  found  associated 
with  all  kinds  of  symptoms. 

The  cause  of  dilatation  is,  as  I  have  said,  a  lack 
of  tonicity  in  the  muscular  wall.  It  is  impossible  to 
account  for  its  appearance,  and  althougli  it  may 
be  spoken  of  as  a  symptom  of  "  atonic  dyspepsia  " 
yet  it  may  be  present  with  no  dyspepsia. 

81.  Structural  Symptoms.  —  Apart  from  the 
evidences  of  dilatation  which  have  been  alluded  to, 
the  symptoms  produced  by  changes  in  the  organ  itself 
are  limited  to  ttie  detection  of  tumours  in  the  stomach 
wall.  In  the  earl}^  stages  they  are  impossible  to 
recognise,  partly  because  ot  the  manner  in  wliicli 
they  occur  as  a  somewhat  diffuse  thickening  of  the 
stomach  wall,  and  partly  because  of  the  unyielding 
contraction  of  the  overlying  muscles.  It  is  only  when 
the  tumour  is  in  the  anterior  wall,  or  has  increased 
to  a  considerable  size,  that  it  can  be  detected.  By 
that  time  the  patient's  condition,  if  the  tumour  is 
malignant,  will  have  suggested  the  serious  nature  of 
the   complaint. 

Constriction  of  the  stomach,  however,  may  arise 
as  a  result  of  contraction  of  gastric  ulcers  (hour- 
glass contraction).  The  detection  of  this  condition 
is  a  matter  of  some  difficulty,  but  it  may  be  suspected 
when  in  washing  out  the  stomach  a  portion  of  tlie 
fluid  poured  in  cannot  be  drawn  off. 

82.  The  Diagnosis  of  Stomach  Affections.— 
From  the  foregoing  discussion  it  will  be  seen  that 
in  the  vast  majority  of  stomach  affections  there  are 
few  signs  that  may  be  considered  distinctive  of  any 


146  Cha2Mr  XIII. 

one  complaint.  When  a  diagnosis  can  at  once  be 
made  in  any  given  case,  the  patient  has  been  suffering 
for  a  considerable  time.  As  the  general  practitioner 
is  usually  consulted  long  before  a  definite  physical 
sign,  as  a  tumour,  blood-vomit,  or  dilatation,  is 
apparent,  and  as  the  symptoms  of  ailments  from 
the  simplest  to  the  most  serious  are  at  first  identical, 
it  is  necessary  to  adopt  other  methods  in  order  to 
arrive  at  a  diagnosis,  such  as  watching  the  progress 
of  the  affection,  its  response  to  treatment,  and  the 
general  condition  of  the  patient. 

As  diets  are  so  varied,  the  personal  predilection 
of  the  doctor  may  lead  him  to  assume  that  the 
patient's  trouble  at  first  is  due  to  some  dietetic  error. 
In  this  he  may  be  right,  and  it  is  always  best  in  any 
given  case  to  start  the  observation  by  ordering  the 
patient  the  simplest  and  most  easily  digested  form 
of  food.  My  own  practice,  in  all  doubtful  cases,  is  to 
attend  to  decayed  and  deficient  teeth,  to  prescribe  a 
diet  in  which  the  food  is  given  in  small  amounts,  the 
solids  dry  so  as  to  ensure  efficient  and  thorough 
mastication,  and  the  fluid  mostly  in  the  form  of  milk, 
also  smaU  in  quantity.  With  people  who  have  to 
foUow  their  dail}^  work  (which  is  the  case  with  the 
majority  of  patients  who  consult  the  general  prac- 
titioner), the  food  should  be  taken  every  two  hours. 
When  at  work  this  may  be  limited  to  a  dry  crust,  to 
be  thoroughly  and  slowly  masticated.  At  other  times 
meat  or  fish  with  dry  bread  or  toast  may  be  given,  if 
the  patient  is  able  to  digest  it  with  comfort.  The 
quantity  must  be  regulated  at  aU  times  by  the  suffer- 
ing of  the  patient.  By  this  simple  process  the 
majority  of  cases  of  indigestion  due  to  error  in  diet 
wiU  be  relieved.     Speed}^  relief  after  such  a  change 


The  Stomach.  147 

of  diet,  or  from  some  simple  remedy,  must  not  be 
taken  as  an  evidence  that  the  stomach  is  free  from 
any  serious  lesion — all  that  has  been  done  has  been 
to  remove  the  stimulus  that  was  adequate  to  produce 
the  reflex  symptom  (pain,  hyperalgesia).  This  is  a 
point  on  which  it  is  necessary  to  insist,  for  many 
€ases  of  severe  stomach  disease  may  be  thus  tem- 
porarily relieved.  In  such  cases  the  history  must  be 
inquired  into,  and  the  presence  of  other  symptoms 
sought  for.  Persistence  of  suffering  and  of  hyperal- 
gesia of  the  epigastric  skin  and  muscle,  with  con- 
tracted recti,  are  signs  usually  indicative  of  ulcera- 
tion. When  these  dietetic  changes  are  foUowed  by 
no  improvement,  rest  in  bed  is  the  next  step,  and  the 
patient  may  have  to  lie  many  months  before  improve- 
ment sets  in.  When  there  is  dilatation,  washing  out 
the  stomach  and  examination  of  the  contents  is  of 
use. 

The  appearance  of  sj^mptoms  of  indigestion  in 
persons  over  the  age  of  forty  years,  with  wasting, 
should  at  once  arouse  the  suspicion  of  malignant 
disease.  In  all  cases  the  appearance  of  the  patient 
should  be  studied,  and  in  case  of  blanching  the  ques- 
tion of  haemorrhage  should  be  carefully  inquired  into. 

The  possibility  of  gall-stone  disease  should 
-always  be  borne  in  mind  in  chronic  forms  of  indi- 
gestion. In  severe  suffering  the  temperament  of 
the  patient  may  aggravate  the  symptoms,  for  the 
reaction  of  a  slight  stomach  lesion  in  a  neurotic 
subject  may  cause  widespread  sensory  phenomena. 

83.  Pain  in  Gastric  Ulcer. — As  gastric  ulcer  can 
frequently  be  definitely  localised,  the  comparison  of 
the  site  of  the  ulcer  with  the  site  of  pain  sheds  a 
light   upon   the    mechanism   of    visceral   pain,    and 


148  Chaj)ter  XIII. 

illustrates  the  practical  value  of  the  method  of 
examination  Adhere  the  reflex  symptoms  are  care- 
fully observed.  I  have  watched  patients  with  gastric 
ulcer  continuously  for  a  great  number  of  years,  and 
have  had  the  opportunity  of  verifying  the  diagnosis 
post  mortem,  or  at  operation,  in  a  good  number.  The 
result  of  these  observations  has  been  to  show  that, 
though  the  actual  site  of  the  ulcer  had  no  direct 
relation  to  the  place  where  the  pain  was  felt,  there 
was  a  fairly  definite  relation  explicable  by  the 
nervous  connection  of  the  parts.  In  many  cases  the 
patient  can  localise  the  pain  with  great  definiteness 
in  some  limited  region,  and  the  skin  and  deeper 
tissues  may  there  be  hyperalgesic.  In  such  cases  I 
have  found  that  when  the  ulcer  was  situated  near  the 
cardiac  end  of  the  stomach  the  site  of  pain  and 
hyperalgesia  was  in  the  upper  part  of  the  epigas- 
trium, when  the  ulcer  was  in  the  middle  of  the 
stomach  the  site  of  pain  and  hyperalgesia  was  in 
the  mid-epigastrium,  and  when  the  ulcer  was  at  the 
pylorus  the  pain  was  felt  at  the  lowest  portion  of 
the  epigastrium. 

To  illustrate,  not  only  the  justification  of  this 
view,  but,  more  important,  its  practical  utility,  I  will 
cite  some  typical  instances.  I  was  called  into  con- 
sultation to  see  a  young  woman  twenty  hours  after 
perforation  of  the  stomach  had  taken  place.  The 
patient  had  suffered  for  many  months  from  pain 
after  food.  She  located  the  site  of  this  pain  with 
great  certainty  in  the  upper  part  of  the  epigastrium., 
over  the  xiphisternum.  I  reasoned  from  this  that 
the  perforated  ulcer  would  be  near  the  cardiac  end 
of  the  stomach.  The  incision  opening  the  abdominal 
cavity  was,  therefore,   made  as  far  to  the  left  as 


The  Stomach.  149 

possible.  On  opening  the  abdomen  there  was  found 
a  large  quantity  of  fluid,  and  a  considerable  quantity 
of  flaky  lymph  covered  most  of  the  exposed  organs. 
The  stomach  was  carefully  searched,  and  we  found  it 
lather  firmlv  adherent  at  the  cardiac  end  to  the 
posterior  wall  of  the  abdomen.  We  inspected  the 
whole  of  the  stomach  except  the  adherent  part,  and 
there  can  be  no  doubt  that  the  adhesions  surrounded 
the  ulcer.  We  resolved  not  to  break  down  these 
adhesions,  as  it  would  have  been  impossible  to  drag 
this  portion  of  the  organ  sufficiently  far  out  to  enable 
us  to  stitch  it.  The  abdomen  was  very  efficienth' 
flushed,  the  wound  stitched  up,  and  the  patient 
made  a  good  recovery. 

Another  patient  I  saw  in  consultation  suffered 
from  peritonitis,  resulting  from  perforation  of  a 
gastric  ulcer.  She  was  a  servant  girl,  twenty  years 
of  age.  For  three  years  she  had  suffered  at  var3dng 
times  from  severe  indigestion,  and,  a  year  previous 
to  my  examination  of  her,  she  had  vomited  a 
quantity  of  blood.  The  pain  from  which  she 
suffered  was  situated  in  the  upper  part  of  the 
epigastrium,  just  over  the  xiphoid  cartilage  (in  the 
shaded  area  of  Fig.  9),  and  was  felt  through  to  the 
back.  When  admitted  to  the  hospital,  the  abdomen 
was  hard  and  tense,  the  pulse  very  soft  and  160  per 
minute.  The  abdomen  was  extremely  tender  to  the 
touch  ;  but  on  closer  examination  this  tenderness 
was  found  to  be  purely  cutaneous,  the  hyperaesthesia 
extending  beyond  the  limits  of  the  abdomen — over 
the  lower  part  of  the  thorax  and  down  over  the 
thighs.  In  a  few  days  the  hypersesthesia  disappeared, 
except  in  a  diffuse,  ill-defined  area  about  the 
epigastrium  :    tiie  greatest  tenderness  always  being 


150 


Chapter  XIII. 


Fig.  9. 

The  shaded  area  shows  site  of  pain,   X  corresponds  to  the  position  of 
the  ulcer  in  the  stomach  as  found  at  the  post-mortem  examination. 


over  the  upper  part  of  the  epigastrium.  The  patient 
sunlc  and  died.  At  the  post-mortem  examination 
there  was  found  much  matting  of  the  stomachy 
bowels,  and  hver  in  the  upper  part  of  the  abdomen 
by  recent  soft  peritonitic  adhesions.  The  stomach 
was  found  perforated  by  a  large  ulcer  near  the  car- 
diac end,  its  position  in  situ  being  nearly  as  far  out 


The  Stomach.  151 

as  the  mid-axillary  line  (indicated  by  x,  Fig.  9). 
There  were  two  other  superficial  ulcers  in  the  imme- 
diate neighbourhood,  but  they  were  nearer  the 
oesophageal  opening  than  the  perforation. 

A  girl,  aged  fourteen  years,  who  had  had  pain 
after  food  for  many  months,  referred  the  situation 
of  the  pain  with  great  precision  to  a  spot  in  the 
middle  of  the  epigastric  region  (Fig.  10).  She  was 
suddenly  seized  with  collapse  and  severe  pain  over 
the  upper  part  of  the  abdomen.  There  could  be  no 
doubt  that  it  was  a  case  of  perforation  of  the 
stomach.  Within  eight  hours  we  opened  the  abdo- 
men, and  as  I  had  noted  the  situation  of  the  pain 
previous  to  the  rupture,  I  suggested  that  the  ulcer 
would  probabty  be  found  in  the  middle  of  the 
stomach.  The  incision  was  therefore  made  well  to 
the  left  of  the  middle  line.  The  perforation  was 
readily  met  Avith  in  the  middle  of  the  stomach  on 
the  lesser  curvature,  in  a  position  corresponding  to 
the  +  in  Fig.  10.  It  was  stitched  up,  and  the  patient 
made  an  excellent  recovery. 

A  female,  aged  thirty-two  years,  for  ten  years  had 
frequentl}^  vomited  large  quantities  of  blood,  and 
suffered  from  severe  pain  in  the  epigastrium.  The 
pain  was  always  felt  with  the  greatest  intensity  at  the 
lower  part  of  the  epigastrium,  corresponding  to  the 
area  shaded  in  Fig.  11.  From  this  region  the  pain 
would  frequently  strike  round  the  left  side,  and  be 
felt  severely  over  the  sixth  and  seventh  dorsal  verte- 
brae. The  painful  area  in  the  epigastrium  was  often 
extremely  sensitive  to  the  touch,  and  the  cutaneous 
hypersesthesia  sometimes  extended  as  a  broad  band 
round  the  left  side.  The  last  note  I  made  about  the 
patient  was  on  1st  April,  1897,  to  the  effect  that  the 


152 


Charier  XI I L 


Fig.   10. 

The  shaded  area  uiiows  the  site  of  pain,  and  the  +  the  position  of  the 
jastric  ulcer  as  found  at  the  operation. 


patient  "  vomited  a  large  quantity  of  blood  yester- 
day. The  pain  is  felt  very  severely  midway  between 
the  xiphoid  sternum  and  the  umbiHcus,  striking 
round  towards  the  left  side  "  ;  and  then  follows  a 
diagram  noting  the  area,  as  marked  in  Fig.  11. 


The  Stomach.  153 

In  treating  this  patient,  at  an  early  date,  a 
l)lister  the  size  of  a  florin  had  been  apphed  over  the 
painful  area  in  the  epigastrium.  So  much  rehef 
was  obtained  when  the  cutaneous  surface  was  raw, 
that  savin  ointment  was  used  to  keep  the  wound 
from  heahng,  until  all  symptoms  of  pain  had  dis- 
appeared. During  the  last  five  years  of  her  life  (she 
died  of  phthisis)  the  patient  had  been  in  the  habit, 
from  time  to  time,  of  applying  the  blister  herself 
whenever  there  was  a  recurrence  of  the  pain.  At 
the  post-mortem  examination  the  effects  of  a  recent 
blister  were  still  evident,  as  a  superficial  erosion, 
occupying  the  lower  part  of  the  epigastrium,  corre- 
sponding exactly  with  the  area  shaded  in  Fig.  11. 

The  patient  died  suddenly  on  7tli  July.  At  the 
post-mortem  examination  held  next  day,  an  ulcer, 
1  in.  in  diameter,  with  slightly  thickened  edges,  was 
found  situated  partly  in  the  stomach  and  partly  in 
the  pylorus.  I  requested  my  colleague.  Dr.  Brown, 
to  note  exacth'  what  position  the  ulcer  occupied  in 
relation  to  the  external  bod}'  wall,  and  he,  carefully 
noting  the  situation,  indicated  an  area  corresponding 
to   X  in  Fig.  11. 

Another  case  had  been  under  my  care  for  ten 
years  for  repeated  attacks  of  epigastric  pain.  The 
pain  in  this  case  was  very  constant,  unless  during 
three  pregnancies  when  she  was  quite  free.  She  con- 
sulted an  eminent  surgeon  who  wrote  to  me  stating 
that  tlie  patient  had  an  ulcer  in  the  middle  of  the 
stomach  and  on  the  posterior  wall,  and  he  recom- 
mended an  operation  for  her  relief.  1  re-examined 
the  patient  and  made  the  following  note  in  my  dairy  : 
"That,  inasmuch  as  the  pain  is  situated  at  the  lowest 
part   of  tlio  epigastric  region,   and  as  there  is  also 


154 


Chapter  XIII. 


Fig.   11. 

The  shaded  area  shows  the  site  of  pain,  x  the  site  occupied  by  the- 
ulcer  at  the  pyloric  orifice  of  the  stomach  as  found  at  the  post-mortem 
examination. 


here  a  limited  area  of  tenderness  of  the  skin,  the 
ulcer  should  be  found  at  the  pyloric  orifice."  This 
latter  view  was  verified  at  the  operation  subsequently 
performed. 

A  patient  whom  I  had  attended  for  twelve 
years  with  mitral  stenosis,  and  who  died  in  1907, 
aged  thirty-six,  suffered  severely  from  gastric  ulcer 


The  Stomach.  155 

in  1899,  so  that  she  had  to  be  kept  in  bed  for  two 
months,  and  be  fed  with  the  greatest  care.  The  pain 
gradually  abated,  but  kept  recurring  at  intervals. 
It  wa3  always  referred  to  the  epigastrium,  but 
radiated  widel}^  Thus  I  made  this  note  on  INlay 
13th,  1903  :  "  Has  severe  pain  starting  at  the  shaded 
area  (as  in  Fig.  11)  and  passes  round  to  the  left  side. 
There  is  no  tenderness  of  the  skin  or  muscles,  and 
no  vomiting.  Stomach  resonance  as  low  as  the 
umbilicus."  She  died  in  February,  1907,  from  her 
heart  affection,  and  at  the  post-mortem  examination 
an  ulcer  was  found  at  the  pyloric  end  of  the  stomach 
— at  some  distance  from  the  epigastrium.  The 
relative  positions  of  the  site  of  pain  and  of  the  ulcer 
were  the  same  as  shown  in  Fig.  11. 


(     156     ) 


Chapter    XIV. 

THE    LIVER,    GALL-BLADDER    AND   DUCTS. 

84.  Nerve  Supply. 

85.  Reflex  Symptoms  in  Gall-stone   Disease. 

86.  Gastric  Symptoms   in    Gall-stone    Disease. 

87.  The  Result  of  Reflex  Symptoms. 

88.  Functional  Symptoms  in   Gall-stone    Disease. 

89.  Structural  Sympto^ns  in    Gall-stone    Disease. 

90.  Fever  in  Gall-stone   Disease. 

91.  Nature  of    Reflex  Symptoms  in    Affections  of 

the  Liver. 

92.  Functional  Symptoms  in  Affections  of  the  Liver. 

93.  Structural  Symptoms  in  Affections  of  the  Liver. 

84.  Nerve  Supply. — The  symptoms  associated 
with  the  liver,  gall-bladder,  and  ducts,  in  many  cases 
resemble  those  of  the  stomach  so  closely  that  there 
is  often  a  difficulty  in  differentiating  the  one  from 
the  other.  This  will  be  understood  when  it  is  borne 
in  mind  that  developmentally  the  liver  and  its 
appendages  are  an  outgrowth  of  the  digestive  tube 
immediately  below  the  stomach.  The  region  in  the 
cord  from  which  the  nerve  supply  passes  is  at,  and 
immediately  below,  the  region  of  the  stomach  supply, 
from  the  seventh  to  the  ninth  thoracic  ;  so  that  with 
severe  stimulation  the  irritable  focus  in  the  cord  in- 
vades the  nerve  supply  of  the  stomach.  As  in  stomach 


The  Liver,   Gall- Bladder  and   Ducts.         157 

affections,  the  reflex  phenomena  appear  in  the  epigas- 
trium, but  in  gall-bladder  affections  the  hyperalgesia 
is  most  common  on  the  right  side,  and  the  upper  part 
of  the  right  rectus  muscle  becomes  contracted.  The 
symptoms  also  tend  to  spread  to  the  right  side  and 
lower  down  in  the  abdominal  Avail.  In  addition  to 
the  thoracic  nerve  suppty  the  liver  and  gall-bladder 
and  ducts  are  also  supplied  by  the  phrenic  nerve 
(third,  fourth  and  fifth  cervical)  and  by  the  vagus. 

85.  Reflex  Symptoms  in  Gall-stone  Disease. — 
The  reflex  S3'mptoms  in  affections  of  the  liver  itself 
are  often  not  very  distinctive,  while  those  of  the  gall- 
bladder and  ducts  are  frequently  violent  and  very 
characteristic.  This  difference  is  due  to  the  fact 
that  the  former  is  a  glandular  structure,  while  the 
latter  contain  non-striped  muscular  fibres  which,  we 
have  seen,  may  provoke  the  most  violent  sensory 
phenomena. 

The  pain  in  gall-stone  disease  varies  much  in 
severity.  It  may  begin  with  a  sense  of  uneasiness  in 
the  epigastrium,  or  over  the  lower  ribs  on  the  right 
side.  A  small  area  of  cutaneous  or  muscular  hyper- 
algesia may  be  detected  somewhere  in  the  region  in 
which  the  pain  is  felt,  and  also  in  the  upper  portion 
of  the  right  rectus.  This  muscle  ma}^  be  more  or  less 
contracted.  These  symptoms  may  be  slight  and 
variable,  and  continue  for  months  or  years,  or  the 
patient  may  be  seized  suddenly  with  violent  pain, 
with  or  without  these  preliminary  symptoms.  The 
pain  in  the  majority  of  cases  of  gall-stone  colic  is 
situated  in  the  middle  line,  about  the  lower  part  of 
the  epigastrium.  It  may  come  on  gradually  and 
remain  for  an  indefinite  period,  sometimes  varying 
sli(i;litly  in  intensity.     From  this  place  it  tends  to 


158 


ChajJter  XIV. 


Fig.  12. 

The  shaded  area  shows  the  region  of  cutaneous  hyperalgesia  after  an 
attack  of  gall-stone  colic.  The  +  is  the  position  of  a  tender  point  in 
many  cases  in  gall-stone  disease,  and  is  over  the  place  where  a  twig  of  the 
ninth  thoracic  nerve  passes  out  of  the  rectus  abdominis  muscle. 


\ 


spread  to  the  right  side,  and  may  be  felt  with  great 
severity  below  the  edges  of  the  ribs.  Sometimes  it 
may  extend  round  to  the  back,  and  be  felt  most 
severely  over  the  ninth  and  tenth  ribs.  In  rare  cases 
the  pain  may  only  be  felt  in  the  back. 

The  pain,  intermitting  slightly,  may  remain  for 
many  hours,  unless  relieved  by  a  sedative.  Frequenth^ 
after  the  subsidence  of  the  pain  the  skin  and  muscles 
of  the  upper  part  of  the  right  side  of  the  abdomen 


The  Liver,  Gall- Bladder  and   Ducts.         159 

become  ven^  tender  to  touch,  and  the  muscles  hard 
and  contracted.  In  Fig.  12  the  area  of  cutaneous 
hyperalgesia  is  shown  in  the  patient  in  whom  I  first 
discovered  the  presence  of  hyperalgesia  in  1891. 

In  a  great  many  cases,  after  the  subsidence  of 
the  attack,  the  hyperalgesia  may  persist  for  several 
weeks,  and,  during  this  period,  severe  attacks  of 
pain  are  very  hable  to  be  provoked,  so  that  the 
patient  is  scarcely  able  to  move  about. 

In  a  small  percentage  of  cases  pain,  sometimes 
of  great  severity,  is  felt  on  the  top  of  the  right 
shoulder,  striking  down  the  outside  of  the  arm.  It 
is  very  necessary  to  recognise  the  relationship 
between  pain  in  this  region  and  gaU-stones.  I  have 
known  patients  in  whom  there  was  tliis  pain  in  the 
shoulder  and  in  the  arm  treated  for  years  for 
"  neuritis,"  and  the  passage  of  a  gall-stone  has  been 
followed  at  once  by  rehef.  In  many  cases  this 
shoulder  pain  is  not  very  severe,  and  the  patient  may 
not  refer  to  it.  If,  however,  inquiry  be  made,  the 
patients  frequently  declare  they  have  had  pain 
in  the  right  shoulder,  wliich  they  thought  was 
"  rheumatic."  When  this  shoulder  pain  is  severe 
-and  the  chief  complaint,  if  due  to  gall-stone  disease  a 
careful  search  will  reveal  evidences  in  the  upper  part 
of  the  abdomen,  in  the  hyperalgesia  of  the  skin,  in 
the  contraction  of  the  muscles,  and  in  the  history  of 
the  patient  which  leave  little  doubt  as  to  the  cause 
of  the  shoulder  pain. 

86.  Gastric  Symptoms  in  Gall-stone  Disease. — 
In  persistent  "  dyspepsia "  and  heart-burn,  the 
question  of  gall-stones  should  always  be  considered. 
I  have  already  referi'ed  to  the  association  of  pain  on 
the    ingestion    of    food    into    the    stoniach    with 


160  Chapter  XIV. 

gall-stone  disease.  One  frequently  sees  patients  with 
a  history  of  "  acute  gastritis  "  of  which  the  symptoms- 
are  described  as  attacks  of  severe  pain  in  "the 
pit  of  the  stomach,"  or  "  cramp  of  the  stomach,"  fol- 
lowed by  a  period  when  ingestion  of  food  causes- 
pain.  Such  a  history  wih,  in  the  majority  of  cases, 
be  found  really  to  have  been  due  to  gall-stone  colic, 
with  the  subsequent  condition  of  hyperalgesia 
associated  with  an  irritable  focus  in  the  cord. 

Nausea  and  vomiting  are  frequent  accompani- 
ments of  gall-stone  colic,  and  their  occurrence  with 
the  pain  in  the  "  pit  of  the  stomach  "  might  seem  ta 
confirm  the  conclusion  that  the  case  is  one  of 
"  gastritis,"  or  "  cramp  of  the  stomach." 

87.  The  Result  of  Reflex  Symptoms.— When 
we  come  to  consider  the  effect  of  this  hyperalgesia^ 
contracted  muscles  and  exalted  reflexes,  we  get  a 
picture  that  is  often  very  misleading.  After  the 
attacks  of  severe  pain  have  subsided  the  patient  may 
be  unable  to  breathe  freely,  each  inspiration  being 
checked,  as  it  is  in  pleurisy,  by  spasm  of  the  inter- 
costal muscles,  and  severe  pain  may  be  felt  over 
the  lower  ribs  on  the  right  side.  Such  symptoms  are 
sometimes  mistaken  for  pleurisy.  If  a  careful  ex- 
amination be  made,  it  can  be  demonstrated  that 
there  is  an  extensive  field  of  hyperalgesia,  extending 
up  into  the  chest  and  implicating  the  intercostal 
muscles.  The  exercise  of  hyperalgesic  muscles  is 
always  limited  on  account  of  their  increased  tone, 
and  the  tonic  contraction  tends  to  increase  with  their 
continued  action.  It  is  for  this  reason  that  patients 
with  gall-stone  and  persistent  hyperalgesia  of  the 
abdominal  muscles  are  comparatively  at  ease  when 
at  rest.     On  moving  about  there  gradually  comes  on 


The  Lirer,   Gall  -  Bladder  and   Ducts.         161 

a  feeling  of  pain  and  dragging  round  the  abdomen, 
and  the  patient  is  unable  to  "  stretch  "  himself  freely. 
This  is  simph"  due  to  the  fact  that  the  exercise  of 
the  hyperalgesic  muscles  has  increased  their  tonic 
contraction  and  their  sensitiveness,  so  that  their 
exercise  is  painful  and  the  extent  of  their  movement 
becomes  greatly  limited, 

88.  Functional  Symptoms  in  Gall-stone 
Disease. — It  is  in  only  a  small  proportion  of  cases 
that  jaundice  is  present  in  gall-stone  disease.  If 
the  stone  is  situated  in  the  common  duct,  or  can 
cause  pressure  on  the  common  duct,  so  as  to  obstruct 
the  channel,  then  jaundice  arises.  When  the  jaun- 
dice is  so  slight  that  it  is  difficult  to  determine 
whether  it  may  not  be  due  to  a  sallow  complexion,  a 
careful  inspection  of  the  sclerotic  may  reveal  a  faint 
tinge.  It  may  be  necessary  in  cases  of  doubt  to 
examine  the  urine  or  blood  for  minute  traces  of  bile 
pigment. 

89.  Structural  Symptoms  in  Gall-stone 
Disease. — It  is  onh'  in  ver}'  rare  cases  that  gall- 
stones can  be  detected  in  the  gall-bladder.  It  can 
only  be  done  when  the  stones  are  so  numerous  as  to 
cause  a  tumour,  or  when  the  stones  cause  the  gall- 
bladder to  become  distended  with  fluid.  This  can 
only  happen  at  a  late  stage  in  the  disease,  and  when 
all  the  associated  reflex  phenomena  have  disappeared, 
for  the  presence  of  hyperalgesia  means  also  the 
presence  of  a  lively  muscular  reflex,  which  effectually 
prevents  the  hand  reaching  the  gall-bladder.  When 
the  abdominal  muscles  are  lax  the  distended  gall- 
l)ladder  may  be  felt  as  a  tumour,  and,  in  rare 
instances,  the  stones  have  been  palpated.  The  liver 
is  sometimes  said  to  "  enlarge  and  become  tender." 


162  Chapter  XIV. 

As,  however,  the  writers  who  describe  this  have  not 
appreciated  the  association  of  this  so-called  "  tender 
liver "  with  contracted  muscles,  this  observation 
needs  to  be  verified.  For  my  part  I  have  never  been 
able  to  satisfy  myself  as  to  a  slight  liver  enlargement 
when  there  is  hyperalgesia  and  contracted  muscles. 
The  muscles  are  so  tender  on  pressure  and  contract 
so  firmly  that  it  is  impossible  to  palpate  the  liver  ; 
the  percussion  note  also  becomes  altered  with  a 
contracted  muscle. 

90.  Fever  in  Gall-stone  Disease. — In  the  great 
majority  of  cases  of  gall-stone  disease  there  is  no 
fever,  except,  it  may  be,  a  slight  rise  at  the  time  of 
an  attack  of  colic.  In  some  cases  there  is  an  asso- 
ciated inflammation  of  the  gall-ducts,  and,  as  a 
consequence,  febrile  attacks  may  occur  of  a  very 
characteristic  type.  These  are  generally  very  sudden 
in  their  onset  and  in  their  subsidence.  The  patient 
begins  to  feel  chilly  and  shivery,  and  when  his  tem- 
perature is  taken  it  will  be  found  to  be  considerably 
raised — 101-104°.  He  may  have  rigors.  In  the 
course  of  one  to  three  days  the  temperature  returns 
to  normal. 

In  more  advanced  stages  of  cholangitis  the 
temperature  may  remain  continuously  above  normal 
with  frequent  exacerbations.  With  the  formation 
of  pus  the  temperature  usualh^  remains  continuously 
high. 

In  all  obscure  cases  of  intermittent  temperature 
the  possibility  of  gall-stones  should  be  considered. 
Except  malaria,  there  is  no  disease  which  gives  such 
characteristic  febrile  attacks.  In  many  cases  a 
shght  jaundice  can  be  detected. 


The  Liver,   Gall -Bladder  and   Ducts.         163 

91.  Nature  of  Reflex  Symptoms  in  Affections 
of  the  Liver. — I  have  dealt  fully  with  the  reflex 
symptoms  in  gall-stone  disease,  because  in  this  com- 
plaint the}^  are  seen  in  their  most  striking  form.  In 
disease  of  the  liver  the  same  areas  may  be  affected 
though  the  symptoms  are  less  violent.  As  I  have 
pointed  out,  it  is  doubtful  if  the  affections  of  the 
parenchyma  of  an  organ  ever  give  rise  to  pain,  unless 
the  fibrous  covering  is  affected  or  stretched.  As  a 
rule  in  liver  affections  there  is  little  pain,  unless  this 
hyperalgesia  of  the  external  body  wall  and  the  tender 
structures  are  stimulated,  as  in  exercise  of  the 
muscles,  when  pain  will  be  felt  in  the  muscles  so 
exercised.  This  is  well  seen  in  cases  of  rapid  in- 
crease in  the  size  of  the  liver  from  heart  failure, 
when  the  capsule  is  stretched,  and  when,  if  the 
patient  moves  about,  there  is  considerable  pain  felt 
in  the  muscles  over  the  liver,  in  front  and  round  to 
the  back.  The  enlargement  of  the  liver  due  to  heart 
failure  offers  an  excellent  opportunity  for  the  study 
of  the  reflex  symptoms  of  liver  affections.  These 
symptoms  are  seen  most  strikingly  when  the  heart 
failure  sets  in  with  some  rapidity,  as  in  certain  cases 
of  paroxysmal  tachycardia,  especially  when  the 
tachycardia  is  due  to  auricular  fibrillation,  or  where 
heart  failure  sets  in  as  a  consequence  of  the  perma- 
nent establishment  of  auricular  fibrillation.  In  cer- 
tain cases  this  abnormal  rhythm  is  suddenly 
developed,  and  in  the  course  of  a  few  hours  the  heart 
dilates  and  the  liver  becomes  very  considerabl}' 
enlarged.  If  the  patient  keeps  at  his  work,  feeling 
weak  and  breathless,  severe  pain  is  suffered  from 
across  the  back  and  round  in  front  over  the  liver.  If 
he  be  examined  a  patch  of  cutaneous  hyperalgesia 


164  Chapter  XIV. 

may  be  found  embracing  a  considerable  portion  of 
the  upper  part  of  the  right  side  of  the  abdomen. 
The  muscles  below  the  ribs  in  front  will  be  found 
hyperalgesic  and  contracted,  and  the  erector  spinae 
muscles  at  the  level  of  the  eighth  to  twelfth  ribs  will 
also  be  found  hyperalgesic  {see  Fig.  16,  page  234).  If 
the  heart  should  suddenly  return  to  the  normal,  the 
liver  enlargement  subsides  in  a  few  hours,  and  the 
hyperalgesia  disappears.  If,  however,  the  abnormal 
rhythm  persists,  then  with  rest  in  bed  the  hyperal- 
gesia gradually  diminishes  until  one  can  palpate  the 
liver  through  the  abdominal  wall,  and  even  take 
tracings  from  the  enlarged  and  pulsating  liver. 

In  enlargement  of  the  liver  due  to  other  causes, 
as  hypertrophic  cirrhosis,  cancer,  chronic  and  sub- 
acute abscess,  the  reflex  symptoms  are  of  the  same 
nature  but  less  acute.  I  have  no  experience  of  acute 
inflammatory  affections  of  the  liver,  so  cannot  tell 
the  nature  of  the  symptoms  present. 

Severe  and  persistent  vomiting  may  arise  in 
liver  affections.  In  the  early  stages  of  "  catarrhal 
jaundice,"  before  the  jaundice  appears,  the  patient 
may  suffer  from  the  most  violent  and  persistent 
attacks  of  vomiting,  and  the  cause  may  remain 
unsuspected  till  the  jaundice  appears. 

92.  Functional  Symptoms  in  Affections  of  the 
Liver. — Jaundice  is,  of  course,  the  most  striking, 
and  needs  no  further  description.  In  all  cases  of 
sallow  or  dirty  grey  complexion,  the  liver  should  be 
carefully  examined.  When  chronic  liver  affections 
produce  jaundice,  or  alter  the  complexion,  there  is 
generally  present  also  a  considerable  degree  of  wast- 
ing. This  wasting,  with  an  enlarged  liver  and  a  faint 
jaundice  tinge,   is   very   suggestive   of   malignancy. 


The  Liver,   Gall -Bladder  and   Ducts.         165 

In  some  cases  of  chronic  heart  failure  there 
may  be  wasting,  enlarged  liver,  jaundice,  slight  or 
severe,  which  simulate  malignancy  so  closeh"  that  a 
mistaken  diagnosis  is  not  uncommon.  If  the  heart 
be  examined  the  evidences  of  heart  disease  are 
always  so  marked  that  no  difficult}^  should  be  met  in 
recognising  the  real  nature  of  the  hver  trouble. 

93.  Structural  Symptoms  in  Affections  of  the 
Liver. — Xormalh'  the  upper  margin  of  the  liver 
dullness  corresponds  to  a  transverse  line  drawn  at 
the  level  of  the  junction  of  the  sternum  and  the 
xiphi-sternum.  The  lower  edge  corresponds  in  the 
nipple  line  to  the  right  costal  margin. 

Organic  sj'mptoms  may  be  recognised  as  an 
enlargement  of  the  organ,  or  a  diminution  of  its 
size.  When  there  is  much  muscular  hyperalgesia  it 
is  often  difficult  to  define  the  limits  of  the  organ. 
In  the  absence  of  this,  little  difficulty  is  found  in 
detecting  the  extent  of  the  liver  enlargement.  This 
is  better  done  by  palpation  than  by  percussion,  as  a 
distended  bowel  ma}"  communicate  a  resonant  note, 
particularly  with  enlargement  of  the  left  lobe.  In 
enlargement  of  the  organ  from  heart  failure  the 
organ  can  sometimes  be  felt  to  pulsate.  This  is  per- 
ceived by  putting  the  left  hand  behind  and  pressing 
forward  the  liver,  while  the  right  hand  is  laid  over 
the  liver,  which  will  be  found  to  heave  gently  with 
each  cardiac  contraction.  The  extent  to  which  the 
liver  may  enlarge  is  very  great,  and  its  lower  margin 
may  extend  as  low  as  the  brim  of  the  pelvis. 

The  surface  of  the  enlarged  liver  niay  be  nodu- 
lar, as  in  cancer  and  cirrhosis.  In  the  great  majority 
of  cases  the  enlargement  of  the  liver  is  downwards, 
but  in  hydatids  of  the  liver,  the  cyst  being  on  the 


166  Chapter  XIV. 

upper  margin,  the  liver  dullness  may  extend 
upwards  to  the  third  rib.  Percussion  gives  rise  to 
the  characteristic  thrill  due  to  vibration  set  up  in 
the  fluid  contents  of  the  cyst. 

The  liver  may  be  pushed  down  by  abnormal  con- 
ditions in  the  chest,  as  in  emphysema  or  pleural 
effusions,  or  it  may  be  displaced  downwards  on 
account  of  laxity  of  its  ligaments  and  of  the  abdo- 
minal muscles  (hepatoptosis). 

It  may  be  dragged  up  into  the  chest,  as  in  the 
retraction  that  follows  the  absorption  of  a  long- 
standing pleuritic   effusion. 

Diminution  of  the  size  of  the  liver  may  occur, 
as  in  atrophic  cirrhosis,  when  it  is  the  lower  border 
that  recedes. 


(     167     ) 


Chapter  XV. 

THE     GREAT     AND     S:\IALL     INTESTINE. 

94.  Difficulties  in    Diagnosis. 

95.  Pain. 

96.  Appendicitis. 

97.  Affections  about  the  Anus  and  Perineum. 

98.  Perineal  Reflex. 

99.  Functional  Symptoms. 
100.  Structural  Sy^nptoms. 

94.  Difficulties  in  Diagnosis. — The  difficulties 
in  diagnosis  of  affections  of  the  bowels  are  very 
great.  The  great  length  of  the  tube,  with  its  coils 
confusedly  mixed  so  that  there  is  no  safe  guide  to 
the  localit}^  of  manj/  portions,  the  continual  shifting 
of  each  portion  with  the  peristalsis  of  the  gut,  and 
our  very  imperfect  knowledge  of  many  of  its  func- 
tions, all  combine  to  render  diagnosis  of  bowel 
affections  a  matter  of  great  uncertainty.  There  is  a 
misconception,  almost  universal,  as  to  the  position 
and  form  of  the  great  intestine,  many  pictures  of 
this  portion  of  the  gut  showing  it  as  passing  in 
swelling  folds  up  the  right  side,  across  the  upper 
part  of  the  abdomen,  and  down  the  left  side  from 
the  splenic  flexure  tc  the  rectum.  It  is  further  stated 
that  the  position  of  this  gut  can  be  made  out  by  per- 
cussion. With  the  exception  of  the  caecum,  which 
is  more  or  less  fixed  in  its  place,  and  usually  dis- 
tended with  gas,  no  part  of  the  gut  can  be  accur- 
ately mapped  out.     To  Ix'ilin  witli,  it  is  doubtful  if 


168  Chapter  XV. 

the  descending  colon  is  ever  distended  in  the  manner 
shown  in  the  pictures.  When  empty  of  faeces  it  lies 
behind  coils  of  small  intestine,  a  contracted  narrow 
tube.  The  study  of  the  movements  of  the  bowel 
after  bismuth  meals  shows  that  the  transverse  colon 
varies  extraordinarily  in  its  position  in  different 
people.  The  ready  distension  of  any  portion  of  the 
small  intestine  renders  attempts  to  differentiate  the 
particular  portion  distended  a  matter  of  the  greatest 
uncertainty. 

A  similar  confusion  exists  in  regard  to  the 
localisation  of  pain.  The  sensation  of  pain  is  fre- 
quently so  diffuse  that  no  clear  indication  of  its 
exact  site  can  be  obtained  in  many  cases.  When 
severe  pain  arises  from  peristalsis  the  situation 
can  often  be  localised  with  a  certain  amount 
of  precision,  but  here  the  recollections  of  the 
patient  are  extremely  unreliable.  I  have  fre- 
quently been  struck  by  the  discrepancy  between 
the  patient's  account  of  the  position  of  the  pain 
described  from  memor}^  and  the  actual  position  to 
which  he  refers  the  pain  when  asked  to  locate  it  while 
suffering  from  an  attack  of  pain.  For  this  reason 
the  account  given  by  the  patient  must  be  taken  with 
great  reserve. 

To  a  certain  extent  the  confusion  also  depends 
on  the  shifting  of  the  site  of  pain.  The  cause  of  pain 
in  the  intestine  is  often  due  to  strong  peristalsis, 
and  in  disease  the  peristalsis  often  does  not  appear 
at  the  site  of  the  lesion,  but  at  some  distance  above 
it,  whence  it  gradually  descends,  and  as  the  wave 
passes  over  coil  after  coil  the  position  of  the  pain 
shifts  likewise.  Peristalsis  may  be  stimulated  below 
the   disease,    as,   for  instance,    when   the   irritating 


The    Great  and  Small   Intestine.  169 

secretion  from  an  inflamed  portion  of  the  gut  causes 
painful  peristalsis  as  it  is  conveyed  along  the  bowel. 

On  account  of  these  and  other  reasons  the 
diagnosis  of  bowel  conditions  is  often  extremely 
unsatisfactory,  though  the  recognition  of  the  difficul- 
ties should  lead  to  a  more  careful  scrutiny  of  the 
symptoms  in  each  individual  case.  In  the  matter  of 
pain,  the  patient  should,  if  possible,  be  interrogated 
at  the  time  he  is  suffering,  and  the  position  of  the 
pain  localised  as  he  feels  it.  If  this  is  impossible, 
then  he  should  be  asked  to  pay  strict  attention  when 
it  recurs  to  note  the  exact  site  of  the  onset  and  the 
subsequent  radiation  of  the  pain. 

95.  Pain. — I  have  already  pointed  out  that  the 
pain  from  peristalsis  of  the  bowel  is  usually  limited 
to  the  central  areas  of  the  bod}^  In  order  to  recognise 
the  area  in  which  the  pain  from  any  given  portion 
of  the  bowel  may  arise,  I  have  taken  careful  observa- 
tions in  cases  of  obstruction  of  the  bowel,  as  one  was 
frequently  able  to  demonstrate  the  site  of  the  lesion 
by  operation  or  post-mortem  examination.  It  is 
well  known  that  the  bowel  below  the  obstruction 
oeases  to  contract  ana  lies  inert.  On  the  other  hand, 
the  bowel  above  the  point  of  obstruction  is  usually 
stimulated  to  violent  peristalsis  in  the  attempt  to 
overcome  the  obstruction.  In  consequence  of  this 
violent  peristalsis  severe  colic-like  pains  are  set  up. 
Careful  observation  of  the  patient  during  an  attack 
will  reveal  the  fact  that  the  pain  starts  high  up  in 
the  abdomen,  passes  gradually  lower  and  lower,  till 
it  reaches  a  climax  at  some  definite  part ;  then  it 
ceases  and  does  not  descend  lower.  If  when  the  pain 
stops  this  part  be  noted,  the  situation  of  tlie  ob- 
struction   can    be    localised    within    certain    limits. 


170  Chapter  XV. 

Unfortunately  the  limits  are  still  wide  ;  nevertheless^, 
the  information  is  extremely  useful.  If  we  take  the^ 
usual  divisions  of  the  areas  of  the  abdomen  as  in 
Fig.  8,  page  117,  it  will  be  found  that  the  peristalsis- 
of  the  small  intestine  gives  rise  to  pain  limited  to 
the  umbilical  region,  never  descending  below  that 
area.  The  cases  in  which  I  have  specially  studied 
the  pains  due  to  obstruction  of  the  small  intestine 
have  been  strangulated  hernias,  and  I  have  had 
abundant  opportunities  in  operating  to  verify  the 
situation  of  the  obstruction.  This  localisation  of 
the  pain  in  the  umbilical  region  is  supported  by 
the  experience  acquired  in  the  case  of  peristalsis,, 
with  the  intestine  exposed,  cited  on  page  40.  An 
attempt  has  been  made  to  find  out  whether  the  local- 
isation might  not  be  more  exact,  by  noting  the  level 
of  the  pain,  but  the  sensation  is  evidently  too  diffusa 
to  permit  of  such  exact  localisation.  One  would 
naturally  expect  to  find  a  distinct  relationship 
between  the  level  of  the  pain  and  the  position  of  the 
obstruction,  but  owing  to  this  diffusion  I  failed  to 
satisfy  myself  in  any  given  case  of  the  exact  limits 
of  the  pain.  The  pain,  when  very  severe  just  at  the 
lowest  limits,  also  extends  widely  across  the  abdomen 
at  the  same  level.  In  many  cases  a  diffuse  area  of 
hyperalgesia  of  the  skin  and  muscles  may  be  detected,, 
but  it  has  been  of  such  a  vague  character  that  I 
have  not  found  it  of  much  value  as  an  aid  in 
diagnosis. 

In  obstruction  of  the  large  intestine  the  pain 
due  to  the  peristalsis  descends  to  the  hypogastric 
region  (Fig.  8,  page  117),  and  here  certain  limited 
deductions  can  be  drawn  from  the  level  at  which  the 
pain  stops.       The  cases  I  have  studied  have  been. 


The   Great  and  Small   Intestine.  171 

patients  with  obstruction  at  the  splenic  flexure,  or 
at  the  sigmoid  flexure,  and  cases  of  hard  masses  of 
faeces  retained  in  the  rectum.  In  the  obstruction  at 
the  splenic  flexure  the  pain  did  not  descend  below 
the  middle  of  the  hypogastric  area,  while  the  pain 
due  to  peristalsis  below  the  splenic  flexure  was  felt 
about,  and  below,  the  middle  of  the  h3^pogastric  area. 
I  have  observed  a  number  of  cases  with  faecal  masses 
in  the  rectum,  too  large  and  hard  for  their  expulsion 
by  the  anus,  the  pain  being  felt  above  the  pubis.  In 
these  cases  the  situation  of  the  pain  and  straining 
efforts  seemed  identical  with  the  pains  and  straining 
during  labour.  This  agrees  with  what  has  already 
been  said  about  the  situation  of  pain  in  diarrhoea  and 
with  distending  enemata  immediately  before  the 
expulsion  of  the  fluid  contents  of  the  rectum. 

In  many  people  scybalous  masses  may  lie  in 
different  parts  of  the  bowel,  and  their  presence  may 
set  up,  after  a  time,  violent  peristalsis,  in  some  cases 
accompanied  by  diarrhoea.  Once  the  violent  peri- 
stalsis begins  it  does  not  subside  until  the  scybalae 
are  shifted.  The  people  in  whom  I  have  observed  this 
most  frequently  have  been  young  women  who  have 
neglected  their  bowels.  The  pains  are  very  severe, 
and  the  motions  will  often  contain  greyish  hard 
lumps.  After  the  bowels  have  been  voided  a  large 
area  of  hyperalgesia  and  muscular  contraction  over 
the  abdominal  wall  is  left.  This  tenderness  and 
hardness  and  the  history  of  colic-like  pains  give  rise 
to  many  wrong  diagnoses,  the  principal  error  being 
to  attribute  the  symptoms  to  peritonitis. 

96.  Appendicitis.^The  nature  of  the  symptoms 
in  appendicitis  lias  already  been  indicated  on  page 
4.3.    From  the  study  of  the  case  given  there  it  will  be 


172  Chapter  XV. 

seen  that  the  symptoms  are  entirety  reflex.  In  ever}^ 
case  there  are  features  pecuhar  to  the  individual,  so 
that  great  variations  as  to  the  amount  of  pain, 
extent  of  hyperalgesia  and  muscular  contraction  are 
met  with.  But  the  nature  of  the  symptoms  and  their 
distribution  and  mechanism  of  production  are  suffi- 
ciently indicated  in  the  illustrative  case  given  on 
page  42  to  make  clear  the  principles  underlying  the 
most  salient  symptoms  of  appendicitis. 

There  are  a  few  symptoms  present  in  excep- 
tional cases  that  need  a  passing  notice.  The  nature 
of  the  attacks  of  "  appendicular  colic  "  is  to  me  very 
obscure.  In  some  cases  the  pains  have  been  so  dis- 
tinctly referred  to  the  umbilical  region  that  I  have 
considered  the  question  whether  the  intestine  above 
the  inflamed  appendix  may  not  have  been  stimulated 
to  violent  peristalsis.  That  the  colic  in  appendicitis 
may  be  due  to  violent  peristalsis,  at  all  events  in 
some  cases,  seems  possible  from  the  following  experi- 
ence. A  man  aged  40  years  had  suffered  for  four 
3^ears  from  violent  attacks  of  colic  and  pain  in  the 
abdomen.  He  had  seen  several  physicians  and  sur- 
geons and  ultim.ately  a  diagnosis  of  gall-stones  was 
made,  and  he  was  operated  upon.  No  gall-stones 
were  found  and  no  relief  was  obtained  from  the 
operation.  I  was  asked  to  see  him  and  I  obtained, 
with  difficulty,  a  clear  notion  of  the  site  of  his 
suffering  and  the  spread  of  the  pain.  The  pain 
started  always  just  at  the  lower  part  of  the  epigastric 
region  and  descended  slowly  in  the  middle,  increas- 
ing in  severity  to  the  lowest  part  of  the  umbilical 
region  (space  c.  Fig.  8,  p.  117).  It  might  stop  in  this 
neighbourhood  for  some  time,  but  did  not  descend 
lower.    From  this  account,  it  was  reasoned  that  the 


The   Great  and  Small   Intestine.  173 

pain  was  due  to  some  hollow  viscus,  that  as  it  per- 
sisted most  severely  in  the  central  regions  of  the 
abdomen,  gall-stone  colic  and  the  colic  from  a  renal 
calculus  could  be  excluded.  The  only  hollow  viscus 
that  could  cause  pain  in  this  region  was  the  small 
intestine,  and  the  radiation  of  the  pain  indicated  that 
the  peristalsis  had  started  high  up  and  stopped  at  the 
end  of  the  small  intestine.  A  painful  peristalsis 
occurs  onl}^  above  the  provoking  cause,  so  that  we 
could  infer  the  cause  would  be  found  at  the  lower  end 
of  the  small  gut.  Moreover,  as  in  the  great  majority 
of  cases  the  appendix  is  the  provoking  agent  at  this 
place,  the  probability  was  that  the  appendix  was 
affected.  Acting  on  this  diagnosis  an  operation  was 
performed.  The  small  intestine  was  found  deeply 
injected,  especially  at  its  lower  extremity,  and  the 
appendix  was  found  red,  inflamed  and  adherent  to  the 
neighbouring  structures,  the  adhesions  obstructing 
the  lumen  of  the  lower  part  of  the  small  intestine. 
The  removal  of  the  appendix  and  adhesions  was 
followed  by  complete  freedom  from  attacks  of  colic. 

The  appendix  wall  itself  contains  a  muscle 
coat,  and  the  contents  are  frequently  confined  by 
blocking  of  the  passage,  so  it  ma}'  perhaps  be  sur- 
mised that  the  colic  arises  from  a  spasm  of  the 
muscle  coat.  The  reference  of  the  pain  to  the  middle 
line  would  be  in  accordance  with  the  experience  that 
peristalsis  of  any  portion  of  the  digestive  tube  causes 
pain  in  the  middle  line,  and  parts  that  have 
developed  from  the  tube,  as  the  gall-ducts  and 
appendix,  follow  the  same  law. 

I  cannot  satisfactorily  account  for  the  predomi- 
nant symptoms  from  the  appendix  being  so  distinctly 
one-sided,  seeing  that  it  is  developmentally  a  portion 


174  Chapter  XV. 

of  the  digestive  tube.  But  it  is  interesting  to  note 
that,  as  in  the  case  of  the  gall-bladder  and  ducts,  and 
even  of  the  heart,  though  the  most  severe  pains  may 
be  situated  across  the  middle  line,  the  radiations  and 
persistence  of  the  phenomena  are  one-sided. 

In  extension  of  the  inflammation  in  appendicitis 
other  structures  become  involved,  and  these  then 
•give  rise  to  the  symptoms  peculiar  to  themselves. 
When  the  inflammation  affects  the  parietal  peri- 
toneum, and  adhesions  form  with  it,  these  symptoms 
will  be  found  characteristic  of  peritoneal  adhesions, 
as  pain  and  tenderness  over  the  part  {see  page  200). 
This  fact  may  account  for  many  of  those  aberrant 
symptoms  in  appendicitis,  as  when  it  is  situated  in 
the  pelvis  and  adherent  to  adjacent  parts. 

97.  Affections  about  the  Anus  and  Perineum. 
— A  somewhat  complicated  series  of  symptoms  arise 
in  affections  about  the  anus,  in  consequence  of  the 
nervous  distribution  passing  gradually  from  the 
autonomic  to  the  cerebro-spinal  system.  As  at  the 
junction  of  other  mucous  and  cutaneous  surfaces  the 
sensibility  becomes  profoundly  modified,  and  there  is 
a  transition  area  where  certain  forms  of  cutaneous 
sensibility,  such  as  pain,  become  more  acute.  This 
difference  in  sensibility  is  well  seen  in  the  case  of 
piles,  for  so  long  as  the  pile  does  not  encroach  upon 
the  tissues  supplied  by  the  cerebro-spinal  nerves,  no 
direct  pain  is  felt,  whereas  pain  of  the  most  distress- 
ing character  is  felt  when  the  pile  encroaches  on  the 
mucous  membrane  supplied  by  the  cerebro-spinal 
sensory  nerves.  Pain,  however,  may  be  felt  from  an 
internal  pile,  and  it  is  then  referred  to  the  back,  over 
the  upper  part  of  the  sacrum.  I  have  seen  much 
relief  afforded  from  this  pain  by  free  haemorrhage 


The   Great  and  Small   Intestine.  175 

from  an  internal  pile.  This  referred  pain  is  some- 
times extremely  distressing  in  cases  of  ulceration 
within  the  rectum,  especialh^  after  the  bowels  are 
moved.  When  the  ulceration  or  fissure  involves  the 
sensitive  marginal  mucous  membrane,  the  pain 
becomes  at  times  agonising  and  prolonged,  and  is 

ielt  in  an  ill-defined  area  all  around  the  anus  and 

ov  er  the  sacrum. 

There  is  an  intimate  relationship  between  this 
region  and  the  bladder,  irritation  at  the  anus  pro- 
ducing frequent  micturition,  and  sometimes  spasm 
of  the  sphincter  vesicae.  This  reflex  is  well  seen  in 
women  where  the  perineum  has  been  torn  at  the  birth 
of  a  child  and  afterwards  stitched  up,  retention  of 
urine  being  a  frequent  result.  This  reflex  is  prob- 
ably limited  to  the  skin  of  the  perineum,  as  if  care 
be  taken  in  stitching  the  perineum  not  to  include  the 
skin  in  the  stitches  retention  of  urine  is  less  likely 
to  occur.  The  skin  supply  for  this  region  is  from 
the  lower  sacral  nerves,  and  the  nerve  supply  for 
the  sphincter  vesicae  is  from  the  autonomic  sacral 
nerves — that  is,  from  the  same  region  of  the  cord. 
98.  Perineal  Reflex.  —  A  curious  connection 
exists  between  the  perineum  and  the  respiratory  and 
other  centres.  This  is  seen  particularly  well  in  par- 
turition, where,  when  the  child's  head  presses  on  the 
perineum,  the  contraction  of  the  uterus  is  sometimes 
greatly  stimulated,  and  the  mother  is  compelled  to 
"  bear  down "  with  uncontrollable  energy.  In 
patients  lightly  under  chloroform  the  traction  niade 
by  the  forceps  when  the  head  reaches  the  perineum 
somewhat  causes  the  patient  to  breathe  in  a  deep 
and  laboured  fashion.  Apart  from  its  scientific 
interest  this  latter  reflex  has  to  bo  borne  in  mind  in 


176  Chapter  XV, 

the  administration  of  chloroform,  as  by  the  deep 
respiratory  movements  a  greater  amount  of  chloro- 
form may  be  taken  than  is  desirable. 

99.  Functional  Symptoms. — Our  knowledge  of 
the  symptoms  arising  directly  from  abnormal  func- 
tions of  the  digestive  tube  is  limited  to  the  condition 
of  the  fsecal  evacuations.  These  again  must  be 
studied  in  association  with  other  phenomena,  as 
pain,  fever,  distension  of  the  abdomen.  It  is  scarcely 
necessary  to  insist  on  the  systematic  examination  of 
the  faeces  by  the  physician  himself  in  all  abdominal 
cases,  and  the  patient  should  be  instructed  to  observe 
for  himself  the  character  of  the  dejecta.  The  char- 
acter of  the  normal  stool  is  fairly  constant,  soft  and 
moulded,  yellowish-brown  in  the  adult,  pale  whitish 
yellow  in  children  and  the  milk-fed.  The  colour 
may  vary  with  the  food  and  with  drugs.  The  absence- 
of  bile  gives  the  characteristic  pale  drab-coloured 
stools.  There  may  be  an  admixture  of  the  stool  with 
abnormal  contents  from  the  intestinal  tract,  as  blood,, 
mucus  and  pus.  Blood  from  near  the  anus,  as  in 
piles,  is  usually  unmixed  with  the  faeces,  either  free 
or  staining  the  faecal  mass.  When  its  origin  is- 
higher  up  it  becomes  mixed  with  the  food,  and  under- 
going certain  chemical  changes,  becomes  black  and 
"  tarry  "  looking.  The  character  of  the  m^ucus  in  the 
stools  may  give  some  idea  as  to  its  source  ;  small 
jelly-like  masses  accompany  the  diarrhoea  from  an 
inflamed  swollen  gut,  shreds  or  membrane-like  pieces- 
are  seen  in  affections  of  the  colon  and  rectum.  Other 
abnormal  constituents  may  be  present,  as  undigested 
food,  gall-stone,  intestinal  sand. 

The  character  of  certain  stools  is  fairly  typical,. 
as    the    diarrhoeic,    with    hard    scybalous     masses,. 


The  Great  and  Small  Intestine.  177 

indicating  that  scj^balse  are  lodged  in  some  part  of  the 
digestive  tract,  and  setting  up  irritation  ;  the  "  pea- 
soup  "  stools  of  typhoid  fever  and  of  pneumonia  ;  the 
"rice  water  "  stools  of  cholera  ;  the  "  frothy  stools  " 
of  infantile  cliarrhcea.  The  shape  of  the  stool  may 
be  modified  by  its  passing  through  a  constricted 
passage  near  the  anus.  The  recognition  of  obstruc- 
tion, partial  or  complete,  need  not  be  insisted  upon. 

Indirectly  there  are  signs  of  functional  dis- 
turbance, as  in  the  poor  nutrition.  Absorption  of 
toxic  products  ma}'  interfere  with  the  functions  of 
other  organs,  particularly  the  heart,  causing  weak- 
ness, irritability,  and  pain.  The  skin  of  the  armpits 
and  of  the  abdomen  may  become  of  a  dirt}^  j^ellow 
colour  from  the  same  cause. 

100.  Structural  Symptoms. — Symptoms  due  to 
changes  in  the  bowels  are  very  often  difficult  to  make 
out,  owing  to  the  mobility  of  these  organs,  and  the 
ease  with  which  they  can  become  distended  with 
flatus.  Except  the  caecum  and  a  small  portion  of 
the  ascending  colon  and  the  rectum,  there  is  no  part 
in  which  changes  can  be  with  certainty  located  on 
account  of  shifting  and  distension  of  the  intestinal 
coils.  In  addition  to  this,  tumours  and  thickenings 
in  any  part  of  the  abdomen  so  readily  conve}"  the 
tympanitic  note  from  the  bowel  that  percussion  is 
seldom  of  much  use  in  detecting  these  when  they  are 
in  the  walls  of  the  bowel.  A  further  complication 
arises  when  small  portions  of  the  muscles  of  the 
abdominal  wall  become  hard  and  contracted  {see 
page  72).  Manifest  changes  in  the  bowels  should 
alwaj's  be  considered  with  reference  to  the  reflex 
phenomena  already  described. 


(     178     ) 


Chapter  XVI. 

AFFECTIONS    OF    THE    URINARY    SYSTEM. 

101.  Symptoms  of    Affections   of   the    Kidney. 

102.  Symptoms  of    Affections  of    the  Pelvis  of  the 

Kidney  and    Ureter. 

103.  Symptoms  of   Affections  of  the  Bladder. 

101.  Symptoms  of  Affections  of  the  Kidney. —  » 

As  in  the  affections  of  other  glandular  organs, 
there  are  practically  no  sensory  symptoms  evoked 
by  disease  of  the  kidney  structure.  Backache  is 
sometimes  put  down  as  present  in  inflammation  of 
the  kidney,  but  considering  how  frequent  backache 
is,  some  doubt  may  be  entertained  whether  the  kidney 
is  the  cause.  For  a  great  many  years  I  have  carefully 
inquired  into  the  symptoms  in  all  sorts  of  cases  of 
albuminuria,  acute  and  chronic,  and  I  could  find  no 
evidence  of  pain  of  any  form  referable  to  the  kidney 
trouble.  Ail  the  symptoms  of  kidney  disease  (apart 
from  alteration  in  the  size  of  the  organ)  are  found 
in  the  chemical  examination  of  the  urine,  in  the 
frequent  micturition,  or  as  the  result  of  its  impaired 
secretion  on  other  organs  and  systems  (vomiting, 
headache,  convulsions,  changes  in  the  cardio-vascular 
system,  dropsy). 


Affections  of  the    Urinary  System.  179 

Functional  Symptoms. — In  the  routine  exami- 
nation of  all  cases  inquiry  should  be  made  into  the 
question  whether  the  patient  has  to  get  up  at  night 
to  pass  urine,  and,  if  such  is  the  case,  the  urine 
should  be  examined  for  albumen  or  sugar.  The  pres- 
ence of  albumen  should  lead  to  the  careful  examina- 
tion of  other  systems,  particularly  the  heart  and 
blood  vessels,  because  it  is  the  effect  of  the  impaired 
kidney  function  on  these  that  offers  the  best  guide 
as  to  the  importance  of  the  albuminuria.  It  must  be 
borne  in  mind  that  the  presence  of  albumen  is  not  in 
itself  a  matter  of  moment.  It  only  indicates  that 
albumen  is  passing  through  the  secretory  cells,  and 
long  experience  has  taught  that  when  this  happens 
there  is  an  injur}^  to  these  cells  which  prevents  the 
ehmination  of  other  matters,  which,  being  retained 
in  the  blood,  have  a  deteriorating  influence  on 
other  organs.  It  is  for  this  reason  that  the 
significance .  of  the  kidney  affection  is  often  deter- 
mined by  the  symptoms  in  other  organs  and 
tissues. 

Structural  Symptoms. — It  is  only  when  there  is 
a  considerable  increase  in  the  size  of  the  kidney  that 
we  can  detect  its  presence  clinically  with  assurance. 
And  even  then  the  subject  has  to  be  of  a  somewhat 
spare  habit.  Normally  we  recognise  a  certain  full- 
ness under  the  lower  ribs  in  either  flank,  which 
rather  indicates  its  presence  than  gives  a  clue  to  its 
size.  It  is  the  relative  greater  fullness  on  one  side 
that  leads  to  the  recognition  of  the  increase  in  the 
size  of  this  organ,  and  the  absence  of  this  fullness 
which  leads  to  the  suspicion  of  a  displaced  kidney. 
Tlie  nature  of  the  enlargement  in  any  given  case  is 
surmised  from  the  presence  of  other  symptoms,  as 


180  Chapter  XVI. 

pus  or  tubercle  bacilli  in  the  urine,  the  cancerous 
cachexia,  etc. 

Movable  Kidney. — The  careful  palpation  of  the 
abdominal  cavity  with  the  walls  relaxed  may  reveal 
a  movable  kidney.  It  is  often  present  without  symp- 
toms, but  its  presence  may  be  associated  with  a  good 
deal  of  vague,  indefinite  pain,  dilatation  of  the 
stomach,  and  more  or  less  nervous  disturbance  of  a 
"  neurasthenic  "  kind.  Obscure  attacks  of  vague 
pains,  nausea  and  collapse  have  been  ascribed  to  a 
movable  kidney,  and  it  is  well  to  bear  this  in  mind, 
for  such  attacks  may  be  attributed  to  appendicitis 
or  other  intestinal  lesion,  or  to  renal  colic. 

102.  Symptoms  of  Affections  of  the  Pelvis  of 
the  Kidney  and  Ureter. —  Nerve  Supply  of  the 
Ureter. — The  efferent  nerves  supplying  the  pelvis  of 
the  kidney  and  the  ureter  come  from  the  inferior 
mesenteric,  spermatic  and  hypogastric  plexuses.  The 
level  at  which  these  nerves  leave  the  cord  can  be 
inferred  from  the  study  of  the  nerves  implicated  in 
the  reflex  phenomena  in  cases  of  renal  calculus. 
From  this  study  the  nerves  passing  from  the  pelvis 
of  the  kidney  and  the  ureter  can  be  inferred  to 
reach  the  spinal  cord  at  the  level  of  the  lower 
thoracic  and  upper  lumbar  nerves.  The  distribu- 
tion of  the  pain  and  the  stimulation  of  the  muscles 
to  contraction,  in  a  case  of  renal  colic,  such  as  that 
described  on  page  44,  give  a  clue  to  the  cerebro- 
spinal nerves  reflexly  stimulated  by  the  sympathetic 
nerves  from  the  pelvis  of  the  kidney  and  the  ureter. 
The  pain  arising  in  the  back  above  the  crest  of  the 
ilium,  passing  round  the  front  and  slanting  down 
into  the  testicle,  as  in  the  shaded  area  of  Fig.  13, 
page    183,    traverses   the   fields    of    distribution    of 


Affections  of  the    Urinary  System.  181 

several  spinal  nerves  from  the  eleventh  thoracic  to 
the  second  lumbar.  In  like  manner  the  contraction 
of  the  muscles  that  accompany  the  pain  gives  a  clue 
to  the  motor  cerebro-spinal  nerves  that  have  been 
stimulated.  In  the  case  described  on  page  44  con- 
traction of  the  fiat  muscles  over  the  ihac  fossa  (the 
external  and  internal  obliques,  and  the  transversalis 
abdominis)  was  produced,  the  lower  portion  of  these 
muscles  being  supplied  b}'  the  lower  thoracic  nerves. 
The  contraction  of  the  cremaster  muscle,  which  is 
often  such  a  distinct  feature  in  cases  of  renal  colic, 
implies  a  stimulation  reaching  the  spinal  cord  at  the 
level  of  the  first  and  second  lumbar  nerves.  It  is 
interesting  to  note  that  a  portion  of  the  fibres  of  the 
cremaster  are  continuous  with  the  internal  oblique, 
and  both  of  these  muscles  contract  in  renal  cohc. 
The  genital  branch  of  the  genito-crural  nerve  con- 
tains tlie  motor  nerve  to  the  cremaster  muscle,  and 
also  the  sensory  nerve  to  the  tunica  vaginalis,  which 
latter  becomes  so  hyperaesthetic  in  renal  colic  when 
the  pain  "  shoots  into  the  testicle,"  and  it  is  manifest 
that  it  is  to  the  peripheral  distribution  of  this  nerve 
that  the  pain  is  referred.  It  is  to  be  remembered 
that  the  scrotal  covering  of  the  testicle  is  supplied 
by  the  sacral  nerves,  and  the  skin  of  the  scrotum  is 
never  affected  in  renal  colic.  (For  further  evidences 
of  testicular  sensibility  see  p.  37.) 

Non-striped  muscle  enters  into  the  structure  of 
the  pelvis  of  the  kidney  and  of  the  ureter,  and  in 
consequence  we  have  the  reflex  symptoms  developed 
to  a  very  marked  and  characteristic  extent.  Wliile 
any  circumstances  that  can  arouse  the  severe  con- 
traction of  this  muscle  seem  to  provoke  the  pain  and 
attendant     phenomena,    the    presence    of    a    renal 


182  Chapter  XVI. 

calculus  is,  in  the  great  majority  of  cases,  the 
immediate  cause.  The  following  description,  while 
referring  to  renal  calculi,  also  applies  to  other 
causes,  as  pus  or  tuberculous  ulceration,  which  may 
set  up  a  painful  contraction. 

The  position  of  the  pain,  its  characteristic 
radiation,  and  the  attendant  muscular  contraction, 
have  been  referred  to  and  illustrated  by  the  case 
described  on  page  44.  The  place  where  the  pain 
starts  is  of  very  great  importance  as  giving  an  idea 
of  the  approximate  site  of  the  stone.  It  must  be 
remembered  that  the  gradual  shifting  of  the  pain 
from  the  back  round  to  the  front  and  down  to  the 
groin  is  not  an  indication  that  the  stone  itself  is 
gradually  being  shifted  and  driven  down  the  ureter. 
Nor  must  it  be  imagined  that  because  the  distribu- 
tion of  the  pain  has  a  vague  resemblance  to  our 
notion  of  the  position  of  the  ureter  that  the  pain  is 
felt  "  along  the  ureter."  The  pain  in  its  radiation 
is  passing  along  some  path  in  the  spinal  cord,  and 
thereby  affects  the  cord  centres  of  the  nerves  dis- 
tributed to  the  body  wall  in  the  area  shaded  in 
Fig.  13.  Doubtless  the  peculiar  path  is  directly 
associated  with  the  nerve  supply  of  the  pelvis  of  the 
kidney  and  of  the  ureter,  and  as  each  part  passes 
into  peristalsis  a  definite  portion  of  the  spinal  cord 
receives  a  corresponding  stimulus,  just  as  happens 
in  the  case  of  the  peristalsis  of  the  bowel. 

Bearing  this  in  mind,  it  will  be  seen  that  when 
the  pain  keeps  recurring  and  starting  from  the 
same  place  the  stone  is  stationary,  and  its  presence 
stimulates  a  peristaltic  contraction.  Hence  when  we 
find  repeated  attacks  starting  at  the  back  we  m.ay 
safely  infer  that  the  stone  is  lodged  in  or  near  the 


Affections  of  the    Urinary  System,  183 


Fig.  13. 

The  shaded  area  shows  the  distribution  of  the  cutaneous  hyperalgesia 
after  an  attack  of  renal  colic.  The  band  traverses  portions  of  the  fields 
of  distribution  of  the  eleventh  and  twelfth  thoracic  nerves  and  of  the  first 
lumbar.  The  tunica  vaginalis  and  the  lower  portion  of  the  left  abdominal 
muscles  were  also  hyperalgesic. 


pelvis  of  the  kidney.  There  is  some  doubt  whether  a 
stone  in  the  kidney  surrounded  by  glandular  tissues 
and  not  protruding  into  the  pelvis  can  ever  arouse 
the  pain  characteristic  of  renal  calculus,  for  it  seems 
that  contraction  of  muscle  is  the  cause  of  the  pain, 
and  the  calculus  acts  as  a  stimulus  to  the  contraction. 
The  explanation  of  the  locality  of  the  pain  is 
that  the  spinal  centres  of  some  fibres  of  the  eleventh 
thoracic  nerve  which  are  distributed  in  the  back 


184  ■  Chapter  XVI. 

are  first  stimulated,  that  as  the  peristaltic  wave 
passes  down  it  sends  stimuH  to  other  centres  of 
the  eleventh  and  twelfth  nerves  whose  fibres  are 
distributed  in  the  area  shaded  in  Fig,  13,  and  later  to 
the  genital  branch  of  the  genito-crural  nerve  which 
is  distributed  to  the  tunica  vaginalis  ;  hence  the  pain 
which  shoots  into  the  testicle  and  the  tenderness  of 
the  testicle,  or  rather  of  the  tunica  vaginalis,  after 
an  attack  of  renal  colic. 

In  a  number  of  cases  the  stone  seems  to  stick  on 
its  way  down  the  ureter,  and  the  pains  then  start  at 
a  lower  level.  One  may  sometimes  find  a  patient  with 
a  history  of  attacks  of  pain  starting  in  the  back, 
then  after  a  time  starting  somewhere  in  the  front  of 
the  abdomen  ;  then  they  have  ceased,  and  the  symp- 
toms of  irritation  of  the  bladder  have  appeared  for 
a  period,  followed  by  the  expulsion  of  a  calculus  and 
complete  relief. 

I  am  disposed  to  think  that  in  these  cases  the 
stone  is  lodged  at  the  entrance  of  the  ureter  into  the 
bladder.  We  know  from  observation  on  the  bowel 
that  violent  peristalsis  takes  place  above  the  point 
of  obstruction,  while  the  bowel  below  does  not  con- 
tract, and  it  seems  that  the  same  is  true  of  the  ureter. 
In  these  cases  the  pain  passes  down  as  low  as  the 
testicle,  and  this  would  imply,  if  my  reasoning  is 
right,  that  the  peristalsis  has  extended  to  the  lowest 
portion  of  the  tube.  It  is  not  likely  if  the  stone  were 
lodged  in  the  middle  of  the  ureter,  and  completely 
blocking  the  lumen,  that  a  peristalsis  would  be  set 
up  in  the  part  below.  This  is  a  point  worth  con- 
sidering by  those  who  have  the  opportunity  of 
locating  the  stone  by  operation,  and  seems  to  be 
the  explanation  in  the  following  case. 


Affections  of  the    Urinary  System.  185 

Male,  aged  32,  consulted  me,  A\dth  the  following 
history.  He  had  emigrated  to  America  two  years 
previously.  For  the  first  year  he  had  enjoyed  good 
health,  but  during  the  past  j^ear  he  had  been  in  such 
constant  suffering  that  his  health  was  shattered,  and 
he  had  returned  to  his  native  country,  in  the  hope 
that  the  change  might  do  him  good.  He  was  spare 
and  thin,  walked  with  a  slight  stoop,  and  his  face 
was  drawn  and  anxious.  In  conversation  he  was 
nervous  and  irritable,  and  I  had  the  greatest  diffi- 
culty in  getting  from  him  a  distinct  account  of  his 
complaint,  as  he  had  become  extremely  neurotic,  and 
mixed  his  mental  impressions  and  his  digestive 
troubles  with  the  description  of  pains  in  various 
parts  of  his  body.  With  strict  inquiry  I  found  that 
his  illness  began  with  severe  attacks  of  pain  in  his 
back,  which  he  referred  to  the  left  lumbar  region. 
For  three  months  these  attacks  continued  until  he 
became  weak  and  ill.  After  this  the  pain  shifted, 
starting  over  the  iliac  fossa  and  striking  into  the 
testicle,  and  his  testicle  became  tender,  so  that  it  hurt 
him  to  wear  his  breeches.  In  the  past  few  months 
this  pain  had  disappeared,  and  he  was  now  suffering 
from  great  perineal  pain,  especially  at  the  end  of 
micturition.  From  the  account  given  by  the  patient 
the  salient  points  have  been  selected,  leaving  out  the 
numerous  other  symptoms  from  which  he  suffered, 
and  which  he  had  mixed  up  in  almost  inextricable 
confusion,  besides  giving  his  own  irrelevant 
views  as  he  went  along.  It  was  evident  that 
the  patient  had  had  a  renal  calculus,  which  had 
shifted  its  position  and  was  now  in  his  bladder, 
and  his  long  suffering  had  reacted  on  the 
nervous     system,     producing     very     characteristic 


186  ChapUr  XVI. 

neurotic  or  nem'asthenic  symptoms.  I  somidecl  his 
bladder  and  could  find  no  stone,  but  assured  kim 
that  there  was  a  calculus  in  Ms  bladder.  A  few  days 
after  he  again  called  to  see  me,  a  totall}-  chflferent 
man.  erect  and  sniihng,  and  held  out  to  me,  in  the 
palm  of  his  hand,  a  calculus,  the  size  of  a  smaU 
bean,  which  he  had  passed  the  previous  day.  My 
reading  of  the  symptoms  was,  a  renal  calculus,  at 
first  lodged  in  the  pelvis  of  the  kichiey,  then  at  the 
lower  part  of  the  ureter,  and  finally  in  the  bladder. 
The  suffering  had  weakened  and  exhausted  the  ner- 
vous system  and  produced  other  ^^idespread  pheno- 
mena. I  have  already  drawn  attention  to  the  Avell- 
known  fact  that  prolonged  suffering  tends  to  produce 
a  hypersensitive  nervous  system,  so  that  other  affec- 
tions, such  as  gastric  flatulence,  produce  exaggerated 
symptoms. 

The  reflex  symptoms  resulting  from  a  renal 
calculus  may  be  much  more  extensive,  and  give  rise 
to  s^Tnptoms  indicative  of  other  lesions,  as  already 
referred  to  on  page  76.  There  I  have  instanced  a 
case  where  I  was  summoned  to  do  a  laparotomy  for 
obstruction  of  the  bowel.  When  I  saw  the  patient 
the  s^iTuptoms  certainly  pomted  to  an  obstruction  of 
the  bowel,  for  no  faeces  or  flatus  had  passed  for  two 
days,  the  abdomen  was  greatly  distended,  and  aU  the 
muscles  firm  and  rigid. 

The  nerve  supply  of  the  viscera  and  their  con- 
nection with  the  cerebro-spinal  nerves  is  fairly  con- 
stant. Sometimes  it  would  seem  as  if  the  centres 
in  the  cord  were  at  a  slightly  different  level,  so  that 
the  sensor}'  symptoms  were  referred  to  regions 
higher  or  lower  than  the  usual  level.     Such  is  the 


Affections  of  the    Urinary  Systeyn.  1S7 


Fig.   1-L 

The  shaded  area  corresponds  to  the  ate  of  pain  and  cutaneous  hyper- 
algesia  in  a  case  of  renal  calculus  after  an  attack  of  colic. 


interpretation  I  give  for  the  high  situation  of  the 
sensory  symptoms  in  the  following  case. 

^lale,  born  1864,  consulted  me  in  October,  1900, 
complaining  of  severe  spasms  of  pain  from  wliich 
he  had  been  suffering  five  days.  He  had  had  similar 
attacks  twelve  years  before.  He  referred  the  pain 
with  great  definiteness  to  the  area  shaded  in 
Fig.  14,  page  187,  this  area  corresponding  to 
a    region    of    deep    cutaneous    hyperalgesia — that 


188  Cha'pter  XVI. 

is  to  say,  the  skin  here  was  very  tender  if 
gently  raised  and  gently  pinched,  but  showed  no 
increased  sensitiveness  to  light  scratching  with  a 
pin-head.  This  area  of  tenderness  extended  round 
to  the  spine.  I  was  in  doubt  as  to  the  cause  of  these 
attacks  of  pain.  The  onset  and  character  of  the  sen- 
sation corresponded  to  an  attack  of  renal  colic,  but  I 
had  never  seen  a  case  with  the  pain  and  tenderness 
so  high.  Under  treatment  (rest  and  opium)  the 
attacks  subsided.  He  again  consulted  me  for  a 
similar  series  of  attacks  in  October,  1903.  He  had 
had  an  occasional  attack  in  the  interval,  but  they 
were  becoming  more  frequent.  There  was  still 
present  the  characteristic  area  of  deep  cutaneous 
hyperalgesia,  as  in  Fig.  14.  During  one  of  these 
attacks  the  pain  suddenly  passed  into  the  left  lumbar 
region,  and  then  round  to  the  front  of  the  abdomen, 
to  the  groin  and  into  the  left  testicle.  At  the  same 
time  he  was  conscious  of  the  testicle  being  forcibly 
drawn  up.  When  I  examined  him  there  was  much 
tenderness  on  pressing  the  lumbar  muscles  and  the 
left  testicle.  Under  rest  and  opium  the  pain  sub- 
sided, and  two  days  later  in  voiding  urine  he  passed 
a  small  calculus.  There  was  complete  freedom  from 
pain  until  October,  1905,  when  he  again  had  a  few 
attacks  of  pain  referred  to  the  area  shaded  in  Fig. 
14.  This  pain  passed  downwards  to  the  groin  and 
testicle,  and  again  he  was  conscious  of  the  testicle 
being  firmly  drawn  up.  He  rested  in  bed  four  hours, 
and  upon  micturating  he  passed  another  small 
calculus.  He  has  remained  free  from  any  further 
attack. 

103.  Symptoms  of  Affections  of  the  Bladder. — 
The  bladder  in  its  development  is  derived  from  two 


Affections  of  the    Urinary  System.  189 

sources,  the  allantois  and  the  cloaca.  From  the 
former  there  comes  the  upper  division,  and  from 
the  latter  the  fundus  of  the  bladder  (the  trigone). 
The  nerve  supply  of  the  bladder  is  hkewise  from 
two  sources,  from  the  upper  lumbar  region  and 
from  the  sacral  autonomic  (second  and  third  sacral) 
{see  Fig.  1,  page  27).  As  a  result  of  this  nerve  supply 
the  sensory  symptoms  are  felt  in  two  regions,  in  the 
hypogastric  region,  where  the  upper  lumbar  nerves 
are  distributed,  and  in  the  perineum  and  along  the 
penis,  where  the  sacral  nerves  are  distributed.  The 
pain  from  an  over-distended  bladder,  as  in  retention 
of  the  urine,  is  felt  mainly  above  the  pubis,  and 
resembles  in  its  situation  and  character  the  pain  of 
uterine  contraction  or  the  pain  of  peristalsis  of  the 
lower  end  of  the  great  gut.  This  pam  is  intermittent 
in  character,  and  is  due  to  the  passage  of  waves  of 
contraction  over  the  bladder.  When  there  is  much 
irritation  of  the  bladder,  as  in  acute  infiam.mation  of 
its  mucous  membrane,  or  in  the  presence  of  a  stone, 
the  contraction  of  the  bladder  at  the  end  of  micturi- 
tion is  sometimes  very  severe,  and  the  pain  is  then 
felt  both  above  the  pubis  and  in  the  perineum,  also 
along  the  penis.  In  many  cases  of  stone,  the  pain 
from  the  perineum  to  the  point  of  the  penis  is  the 
most  distinct,  being  felt  most  severely  at  the  end  of 
micturition,  but  severely  also  at  other  times,  and 
particularly  if  the  patient  is  jolted.  The  viscero- 
motor-reflex  is  usually  not  well  marked,  but  I  have 
noted  contraction  of  the  lowest  division  of  the  recti 
in  cases  of  stone  in  the  bladder. 

The  act  of  micturition  is  a  reflex  that  may  be 
stiiiLulatcd  into  activity  in  a  groat  many  ways.  Nor- 
mally there  is  a  distinct  relationship  between  the 


190  Chapter  XVI. 

distension  of  the  bladder  and  the  act,  filhng  of  the 
bladder  setting  up  refiexly  the  contraction  of  the 
muscular  wall,  which  results  in  the  expulsion  of  the 
urine.  In  the  child  the  act  of  micturition  is  purely 
reflex,  but  with  advancing  age  the  individual 
acquires  m.ore  or  less  voluntary  control  of  the  act  of 
mictiurition. 

In  addition  to  the  muscle  wall  of  the  bladder  the 
abdominal  m.uscles  may  assist  by  compressing  the 
bladder,  and  in  expelling  the  last  drops  the  perineal 
muscles  (especially  the  levator  ani  and  the  accelera- 
tor urinse)  play  an  important  part.  The  act  of 
micturition  in  the  infant,  or  the  calls  to  micturate 
in  the  adult,  may  be  so  frequent  as  to  raise  the 
question  of  some  abnormal  accentuation  of  the 
stimulus.  This  may  arise  in  a  great  many  ways,  as 
in  the  excessive  quantity  of  urine  secreted  (in 
diabetes  and  certain  forms  of  Bright' s  disease),  the 
irritating  nature  of  urine  as  in  concentrated  or  very 
acid  urine,  the  presence  of  abnormal  ingredients  as 
oxalates,  pus,  blood,  calculi.  The  wall  of  the  bladder 
may  be  inflamed  and  irritated,  so  that  a  small  quan- 
tity of  normal  urine  may  serve  as  a  stimulus.  Stimuli 
from  other  organs  and  tissues  affecting  the  spinal 
centres  of  the  bladder  may  provoke  frequent  mic- 
turition, as  in  affections  of  the  kidney,  ureter,  anus, 
and  perineal  region.  Or  there  may  be  an  irritable 
focus  in  the  cord,  due  to  lesion  of  some  other  viscus, 
which  invades  the  bladder  centre,  so  that  impressions 
from  the  healthy  bladder  have  an  exaggerated  effect 
and  cause  the  frequent  micturition  seen  in  such  cases 
as  renal  calculus,  appendicitis,  affections  of  the 
ovar}^  and  uterus,  and  piles.  In  these  cases  there 
wiU  always  be  found  some  region  of  hyperalgesia  in 


Affections  of  the    Urinary  System.  191 

the  external  body  waU  characteristic  of  the  particu- 
lar organ  at  fault.  A  cause  of  frequent  micturition 
often  overlooked  is  over-distension  of  the  bladder 
from  some  such  obstruction  as  enlarged  prostate  in 
the  male,  or  pregnancy  or  pelvic  tumour  in  the 
female.  Examination  of  the  resonance  above  the 
pubes  may  reveal  the  dullness  due  to  a  distended 
bladder  in  the  male,  but  when  there  is  a  pregnant 
uterus,  or  other  tumour,  it  may  not  be  possible  to 
recognise  the  distended  bladder.  The  doctor,  misled 
by  an  account  of  frequent  micturition,  may  fail  to 
detect  the  trouble,  and  ver}^  serious  consequences  may 
result  from  this  being  overlooked.  In  pregnancy, 
with  retention  of  urine  of  this  sort,  the  patient  may 
die  if  relief  is  not  speedih'  obtained. 

Functional  SymjAoms  —  Although  the  chief 
function  of  the  bladder  is  to  retain  and  expel  the 
kidney  secretions,  it,  like  other  mucous  membranes, 
has  a  secretion  of  its  own.  The  secretion  is  normally 
only  perceptible  in  ver}^  delicate  analysis  of  the 
urine.  The  contents  of  the  bladder  may  irritate  the 
mucous  membrane,  so  that  its  secretion  may  be  more 
abundant,  and  may  become  perceptible  as  a  haze  at 
the  bottom  of  the  glass  when  the  urine  has  cooled 
and  stood  for  some  time.  This  mucous  secretion  may 
increase  in  quantity  with  the  irritation  or  inflam- 
mation of  the  bladder  wall,  till  the  urine  becomes 
thick  and  viscid,  and  even  blood-stained,  according 
to  the  degree  of  inflammation.  Pus  also  may  be 
secreted  from  the  inflamed  mucous  membrane,  or 
from  an  ulcer.  These  abnormalities,  however,  are  to 
be  detected  by  following  the  usual  routine  of  urine 
•examination,  with  which  I  do  not  propose  to  deal. 


192  Chapter  XVI. 

Structural  Symptoms. — Changes  of  the  organ 
can  only  be  detected  by  its  increase  in  size  above  the 
pubes,  or  by  exploration  with  the  finger  in  the  rectum 
or  vagina.  In  either  case,  when  abnormalities  are 
detected,  additional  evidence  has  to  be  sought  by 
examination  of  the  bladder  by  the  catheter,  by 
sounding,  by  X-raj^s,  or  by  use  of  the  cystoscope. 


(     193     ) 


Chapter  XVII. 

AFFECTIONS  OF  FEMALE  PELVIC  ORGANS. 

104.  The    Uterus. 

105.  The  Ovaries. 

106.  The    Vagina. 

I  have  been  unable  to  satisfy  myself  as  to  the 
sensibility  of  some  parts  of  the  female  pelvic  organs. 
The  uterus  above  the  cervix  is  certain!}^  insensitive 
to  ordinary  stimuli,  for  I  have  many  times  tested 
the  interior,  with  my  whole  hand  in  the  uterus,  dur- 
ing and  after  labour,  and  in  scraping  out  the 
contracted  uterus.  The  pains  during  labour  are 
undoubtedlv  referred,  as  I  shall  describe  later.  I 
cannot  form  any  definite  opinion  of  the  sensibiUt}^  of 
the  cervix,  or  for  that  matter  of  the  vagina.  In 
regard  to  the  cervix  I  have  been  able  to  pinch  it  and 
to  prick  it,  with  no  sensation,  but  on  the  other  hand 
great  pain  is  often  experienced  when  an  attempt  is 
made  to  dilate  it.  But  whether  this  is  a  direct  or 
a  referred  pain  I  could  not  decide.  The  patient  is 
so  conscious  of  the  stimulation  of  the  external  geni- 
tals and  to  the  discomfort  in  the  sensitive  parts,  that 
her  statements  become  affected  by  suggestion,  and 
the  reference  is  too  confused  to  be  of  use.  In  the 
same  way  the  extent  of  the  supply  of  cerebro-spinal 
nerves  to  the  vagina  is  not  understood,  nor  could  I 


194  Chapter  XVII. 

determine  the  limits  by  stimulation,  for  the  sensory 
nerves  are  modified  for  special  sensations.  The 
tendency  to  exaggerated  reflexes  in  most  cases  adds 
to  the  confusion,  for  such  patients  will  say  they 
experience  a  sensation  before  they  are  stimulated, 
and  in  their  apprehension  they  anticipate  or 
exaggerate  the  result.  A  further  complication 
results  from  the  difficulty  in  diagnosis,  it  being  very 
rare  to  obtain  a  satisfactory  proof  of  the  nature  of 
the  ailment  in  cases  showing  what  seemed  the  most 
typical  evidence  of  referred  symptoms.  In  the  fol- 
lowing brief  description  the  subject  is  dealt  with 
so  far  as  reliable  evidence  could  be  obtained. 

104.  The  Uterus. — The  pain  of  uterine  con- 
traction is  a  distinctly  referred  one,  though  this 
seems  scarcely  probable  on  superficial  observation. 
In  palpating  the  pregnant  uterus  during  labour  the 
onset  of  the  contraction  and  the  pain  are  simul- 
taneous and  evidently  so  distinctly  related  that  it 
seems  improbable  that  the  pain  is  not  a  direct  one, 
especially  when  the  pain  is  so  often  described  as 
being  felt  across  the  abdomen  in  the  region  where  the 
uterus  is  felt  contracting.  But  if  the  matter  be  in- 
quired into  more  carefully  it  will  be  found  that  the 
pain  is  frequently  not  felt  across  the  abdomen,  but 
across  the  back  at  the  level  of  the  top  of  the  sacrum. 
Here  again  the  hasty  observer  has  attributed  the 
pain  to  the  child's  head  "  distending  the  cervix,"  or 
"  pressmg  on  the  lumbar  plexus  "  ;  but  this  pain  is 
referred  here  before  the  cervix  is  distended,  and  also 
after  the  child  is  expelled,  during  the  "  after-pains," 
when  the  uterus  can  be  found  to  contract,  although 
the  patulous  cervix  is  untouched.  This  pain  in  the 
back  is  found  not  only  in  labour  at  full  term,  but  also 


Affections  of  Female  Pelvic  Organs.         195 

during  a  miscarriage.  The  pain  referred  to  the 
front  of  the  belly,  between  the  umbilicus  and  pubes, 
is  also  present  when  the  uterus  is  not  an  abdominal 
organ  but  a  pelvic  one,  as  in  miscarriage,  after- 
pains,  and  other  causes  that  induce  uterine  contrac- 
tion. It  is  well  seen  in  the  severe  spasms  of  pain 
that  occasionally  occur  when  some  fluid  from  a 
vaginal  douche  escapes  into  the  uterus  and  sets  up 
uterine  spasm. 

In  rare  cases  we  may  find  the  pains  due  to  the 
contraction  of  the  pregnant  uterus  referred  to  a 
distinctly  lower  level,  and  in  one  case  the  pains  were 
all  felt  across  the  upper  front  portion  of  the  thighs. 

Ver}^  exact  delimitation  of  the  area  of  pain  is 
not  possible,  but  the  region  in  wliicli  uterine  pain 
may  occur  extends  from  the  tenth  thoracic  to  the 
third  lumbar  nerves,  though  in  any  individual  case 
it  is  restricted  to  a  limited  portion  of  that 
distribution. 

105.  The  Ovaries. — The  nerve  supply  of  the 
ovary  is  not  exactly  known,  but,  like  the  testicle,  its 
development  starts  higher  up  in  the  abdomen  than 
the  position  it  occupies  in  adult  life.  The  testicle 
has  been  shown  to  be  developed  between  the  tenth 
and  twelfth  dorsal  vertebrae,  and  the  nerve  supply 
presumably  comes  from  the  same  region.  So  far  as 
I  have  been  able  to  make  out,  the  pain  felt  in  ovarian 
trouble  is  referred  to  the  lowest  part  of  the  abdomen 
of  one  side,  and  over  the  groin  in  the  position  in 
which  the  testicular  pain  is  felt.  The  lowest  portion 
of  the  abdominal  muscles  in  this  situation  readily 
becomes  hyperalgesic  and  contracted.  This  cliarac- 
teristic  region  of  tenderness  has  often  misled 
observers  into  the  beUef  that  the  pain  evoked  by 


196  Chapter  XVII. 

pressure  in  this  region  was  due  to  a  "  tender  ovary,'* 
a  statement  with  some  truth  in  it,  but  not  in  the 
sense  intended,  for  the  ovary  itself  in  such  cases  is 
not  affected  by  the  pressure,  the  pain  of  the  pressure 
arising  from  the  stimulation  of  the  hyperalgesic 
skin  or  muscle. 

Beyond  an  indefinite  patch  of  hyperalgesia  of 
the  skin  in  the  region  of  the  groin,  extending  some- 
times for  a  variable  distance  down  the  thigh,  I  have 
not  been  able  to  make  out  much  that  is  rehable  in 
regard  to  the  hyperalgesic  area  of  ovarian  disease. 
It  is  in  these  cases  we  often  find  such  widespread 
areas  that  it  is  doubtful  how  much  is  due  to  the 
actual  ovarian  lesion. 

Associated  with  all  forms  of  pelvic  trouble  are 
a  number  of  other  reflexes.  Thus  the  breasts  fre- 
quentty  become  tender,  especially  at  the  menstrual 
period.  A  cough  is  sometimes  spoken  of  as  being 
"  uterine,"  or  of  ovarian  origin,  but  I  have  not  been 
able  to  convince  myself  of  such  a  thing.  Vomiting 
is  a  frequent  reflex  symptom,  particularly  in  preg- 
nancy, but  here  it  is  probably  not  of  a  reflex  nature, 
but  toxsemic.  As  I  have  already  remarked,  it  is 
sometimes  a  pure  reflex,  as  in  the  vomiting  associated 
with  the  uterine  pains.  The  effects  of  stimulation  of 
the  ovary  have  not  led  to  a  very  definite  result,  partly 
because  of  the  difficulty  in  doing  this  without  stimu- 
lating the  sensitive  orifice  (anal  and  vaginal).  The 
ovary,  like  the  testicle,  is  partly  covered  by  germinal 
epithelium,  and  this  may  modify  the  sensitivity. 

106.  The  Vagina. — The  character  of  the  pain 
in  vaginal  affections  is  so  ill-defined  that  it  is  difficult 
to  say  whether  it  is  direct  or  referred.  This  is  seen 
in  the  cases  of  urethral  caruncle,  where  the  pain 


Affections  of  Female  Pelvic  Organs.  197 

may  be  of  a  very  severe  form  and  the  localisation  so 
vague  that  the  detection  of  the  cause  is  often  a 
matter  of  some  difficulty.  It  resembles  in  some 
respects  the  severe  vague  pain  of  an  anal  fissure. 
A  powerful  reflex  contraction  of  the  muscles  that  act 
as  sphincter  of  the  vagina,  on  certain  conditions  of 
irritation  of  the  vaginal  mucous  membrane,  ma}' 
produce  vaginismus. 


(     198     ) 


Chapter    XVIII. 

PERITONITIS    AND    PERITONEAL 
ADHESIONS. 

107.  Insensitiveness  of  the  Peritoneum. 

108.  Symptoms  in  Peritonitis. 

109.  Symptoms  in  Peritoneal   Adhesions  [Parietal), 

110.  Symptoms  in  Peritoneal  Adhesions  (  Visceral). 

107.  Insensitiveness    of    the    Peritoneum.  —  I 

have  already  referred  to  the  fact  that  the  serous 
surface  of  the  peritoneum  is  insensitive  to  any  form 
of  stimulation,  but  that  the  external  layer  of 
the  parietal  peritoneum  is  an  extremely  sensitive 
structure,  stimulation  of  which  produces  the  sensa- 
tion of  pain  (page  35).  It  is  commonly  assumed  that 
the  peritoneum  is  an  extremely  sensitive  structure^ 
particularly  when  inflamed.  I  must  say,  however, 
that  I  have  found  no  evidence  of  any  increase  in  the 
sensibility  of  the  inflamed  serous  surface  when  I 
have  stimulated  it  directly,  and  I  have  done 
this  repeatedly  in  patients  free  from  any  form 
of  analgesic.  To  a  certain  extent  the  popular 
misconception  of  the  sensibility  of  the  peritoneum 
has  arisen  from  the  fact  that  no  attention  has  been 
paid  to  the  hyperalgesia  of  the  structures  of  the 
external  body  wall,  including  the  external  layer  of 
the  parietal  peritoneum.  The  result  has  been  that 
the  evidence  of  peritonitis  is  almost  invariably  based 


Peritonitis  and  Peritoneal  Adhesions.        199 

on  the  pain  and  tenderness  on  pressure — evidence 
which,  as  I  have  endeavoured  to  demonstrate,  is  not 
due  to  peritonitis,  but  to  the  hyperalgesia  of  the 
structures  of  the  external  wall.  That  peritonitis 
may  produce  these  symptoms  is  true,  but  it  does  so  in 
the  same  way  as  the  viscera  produce  them — i.e.,  by 
reflex  stimulation.  The  reason  of  the  insensibility 
of  the  peritoneum  is  the  same  as  that  for  the  insen- 
sibility of  the  viscera,  namely,  that  the  nerve  supply 
of  the  peritoneum  arises  from  the  sympathetic,  with 
the  exception  of  the  external  layer  of  the  parietal 
peritoneum,  where  the  nerve  supply  is  from  the 
cerebro-spinal  nerves. 

108.  Symptoms  in  Peritonitis. — If  we  take  a 
case  of  acute  peritonitis  a  careful  analysis  of  the 
symptoms  reveals  their  true  nature.  Thus,  in  a  case 
of  ruptured  gastric  ulcer,  where  there  was  an  exten- 
sive peritonitis  limited  to  the  upper  part  of  the 
abdomen  as  shown  b}^  post-mortem  examination,  the 
patient  lay  on  her  back  with  the  knees  drawn  up, 
partly  to  relax  the  abdominal  muscles,  and  partly  to 
avoid  the  pressure  of  the  bed-clothes  on  the  abdo- 
minal wall.  She  shrank  at  the  first  attempts  to  pal- 
pate the  abdomen,  and  when  the  skin  was  tested  it 
was  found  extremely  hyperalgesic,  the  lightest  touch 
producing  the  sensation  of  pain.  The  area  over 
which  this  hyperalgesia  extended  had  no  definite 
relation  to  the  extent  of  the  peritoneal  inflammation. 
Thus,  for  instance,  in  marking  out  the  limits  of  the 
cutaneous  hyperalgesia  1  found  it  extended  for  a  few 
inches  up  over  the  chest  and  down  over  the  thighs, 
the  margin  fading  awa}^  indefinitely.  The  sensibility 
of  the  muscles  of  the  abdominal  wall  could  not  be 
tested  on  account  of  the  liyperalgesia  of  the  skin  over 


200  Chapter  XVIII. 

them.  They  were,  however,  partially  contracted,  and 
the  lightest  palpation  produced  a  rapid  and  strong 
reflex  contraction. 

In  less  extensive  peritonitis  these  symptoms 
may  be  limited  to  a  small  portion  of  the  abdominal 
wall,  and  when  they  are  present  it  is  impossible  to 
distinguish  them  from  the  hyperalgesia  and  muscular 
contraction  due  to  some  visceral  affection.  The 
hyperalgesia  following  an  attack  of  gall-stone  colic, 
or  due  to  a  gastric  ulcer,  is  almost  invariably  attri- 
buted to  a  "  peritonitis,"  and  this  view  is  supposed 
to  be  proved  when,  during  operation  for  gall-stones, 
a  certain  number  of  peritonitic  adhesions  are  found. 
While  peritonitis  can  produce  hyperalgesia  of  the 
external  body  wall,  it  should  always  be  borne  in 
mind  that  the  viscera  can  also  do  this,  and  when 
hyperalgesia  is  found  in  gastric  ulcer,  after  gall- 
stone, renal  or  bowel  colic,  the  cause  of  the  hyper- 
algesia is  in  all  likelihood  not  peritonitis,  but  the 
presence  of  an  irritable  focus  in  the  spinal  cord,  the 
outcome  of  the  violent  visceral  stimulation. 

109.  Symptoms  in  Peritoneal  Adhesions 
(Parietal). — I  have  broken  down  adhesions  and 
found  them  insensitive,  but  when  tlie}^  are  attached 
to  the  parietal  peritoneum,  dragging  on  them  may 
produce  severe  pain.  Ramstrom  also  describes  the 
serous  surface  of  the  parietal  peritoneum  as  insen- 
sitive, but  that  pulling  on  the  adhesions  attached  to 
the  parietal  layer  causes  pain,  thus  agreeing  with  my 
own  observations.  I  attribute  this  to  the  fact  that 
the  inflam.mation  that  resulted  in  the  production  of 
the  adhesions  had  extended  to  the  peritoneal  layer 
supplied  by  the  cerebro-spinal  sensory  nerves.  The 
difficulty   in    distinguishing   between   visceral    pain 


Peritonitis  and  Peritoneal  Adhesions.        201 

and  the  pain  due  to  the  invasion  of  the  external 
body  wall  is  very  great.  In  naany  visceral  aihnents 
the  inflammatory  affection  extends  and  involves  the 
sensitive  structures  of  the  abdominal  wall,  and  with 
this  extension  a  new  train  of  symptoms  arises,  which 
may  lead  to  wrong  inferences  if  these  differences  in 
the  sensibiht}^  of  the  structures  are  not  clearly  kept 
in  view.  One  can  easily  see  how  appendicitis  may 
give  rise  to  symptoms  which  are  entirety  confined  to 
the  reflex  group,  until  the  inflammation  extends  to 
the  abdominal  wafl,  when  another  series  of  symp- 
toms may  arise  which  are  produced  by  a  different 
mechanism,  and  are  detected  in  the  immediate  region 
of  the  inflammation. 

For  the  study  of  the  symptoms  of  adhesions 
those  formed  after  operation  offer  the  best  oppor- 
tunity, inasmuch  as  their  presence  can  be  inferred 
and  the  operation  has  determined  the  condition  of 
the  viscera.  Maylard  says  :  "  It  is  doubtful  whether 
any  opening  of  the  general  peritoneal  cavity  ever 
takes  place  without  the  subsequent  formation  of 
adhesions,  for  no  tissues  of  the  body  seem  so  ready 
to  exude  a. plastic  cementing  material,  which  glues 
almost  at  once  anv  structure  Ivina;  in  contact  with 
it."  It  is  probably  due  to  these  adhesions  that  so 
much  pain  and  tenderness  is  felt  after  some  simple 
abdominal  operation,  even  when  the  operation  is 
purely  exploratory,  and  no  injury  has  been  done 
to  any  viscus.  The  hyperalgesia  in  such  cases  is 
often  muscular,  and  associated  with  a  lively  reflex  of 
the  hyperalgesic  muscles,  so  much  so  that  their  exer- 
cise, as  in  walking,  may  result  in  their  shortening, 
from  an  increase  of  their  tonic  contraction,  for  a 
longer  or  shorter  time.       Small  portions  of  these 


202  Chapter  XVIII. 

muscles  may  remain  firmly  contracted  for  long 
periods,  and  som.etimes  they  so  closely  resemble  a 
tumour  in  the  abdomen  that  it  is  impossible  to 
tell  whether  the  hardness  is  a  contracted  muscle 
or  not. 

In  a  case  of  pyloric  stenosis,  in  which  gastro- 
enterostomy had  been  performed,  muscle  pain  and 
tenderness  persisted  in  the  left  rectus  muscle.  As 
the  patient  experienced  no  relief,  she  again  con- 
sulted the  surgeon  who  had  performed  the  operation. 
He  detected  a  small  tumour  in  the  abdomen,  and 
insisted  on  an  operation  for  its  removal.  I  thought 
the  tumour  was  a  contraction  of  a  portion  of  the 
fibres  of  the  left  rectus  muscle  at  the  upper  portion 
of  the  second  interseptal  division.  As,  however,  the 
surgeon  was  very  confident  of  his  opinion,  and  I  was 
less  sure  of  mine,  the  abdomen  was  opened.  No 
tumour  was  detected,  but  there  were  numerous  fine 
adhesions  attached  to  the  parietal  peritoneum, 
stomach,  and  bowel.  It  was  manifest  that  the 
apparent  tumour  had  been  entirely  muscular,  this 
contraction  being  in  the  nature  of  a  reflex,  for  there 
was  no  extension  of  the  inflammation  from  the 
adhesions  to  the  muscles. 

110.  Symptoms  in  Peritoneal  Adhesions 
(Visceral). — Adhesions  limited  to  the  visceral  peri- 
toneum may  produce  no  symptoms,  or  they  ma}^  pro- 
duce very  well-marked  reflex  contraction  of  the  mus- 
cles, with  more  or  less  hyperalgesia  of  the  skin  or 
muscles.  This  subject  has  not  been  worked  out,  and 
I  have  only  been  able  to  investigate  it  to  a  limited 
extent.  It  seems,  however,  one  worthy  of  attention, 
and  there  are  plenty  of  opportunities  for  its  study, 
if  careful  notes  of  the   condition   be  made  before 


Peritonitis  and  Peritoneal  Adhesions.        203 

operation.  For  man}^  j-ears  I  applied  it  in  the  diag- 
nosis of  ovarian  tumours  to  ascertain  whether  there 
were  hkel}'  to  be  adhesions  or  not.  Then  I  found 
that  when  the  muscles  of  the  belly-wall  were  not 
contracted  and  not  tender  there  were  no  adhesions 
between  the  ovarian  cyst  and  surrounchng  structures. 
When,  however,  there  was  much  muscular  contrac- 
tion and  h3'peralgesia,  adhesions  were  always  found 
between  the  tumour  and  the  surrounding  organs. 
As,  however,  these  observations  were  made  and  veri- 
fied in  only  some  twent}"  cases,  they  are  manifestly 
insufficient  for  a  definite  statement,  but  I  put  forth 
this  suggestion  as  a  line  of  observation  well  worth 
consideration. 


(     204     ) 


Chapter  XIX. 

AFFECTIONS  OF  THE  LUNGS  AND  PLEURA. 

in.  Nature  of  the  Subjective  Sensations. 

112.  The  Respiration. 

113.  Reflex  Symptoms. 

114.  Functional  Symptoms. 

115.  Structural  Symptoms. 

116.  Affections  of  the  Pleura. 

117.  Nature  of  the  Pain  in  Pleurisy. 

111.  Nature    of    the    Subjective    Sensations. — 

Owing  to  the  constitution  and  the  accessible  situation 
of  the  organs,  the  ph^^sical  signs  of  affections  of  the 
lungs  are  readily  ascertained,  and  have  been  so  well 
explored  that  I  shall  do  little  more  than  touch  upon 
some  of  the  reflex  phenomena.  Even  though  these 
phenomena  can  be  so  readily  recognised,  their 
mechanism  is  far  from  clear.  The  chief  reflex  which 
presides  over  the  movements  of  respiration  involves 
the  employment  of  the  muscles  of  the  body-wall  over 
such  a  large  area  that  the  symptoms  often  become 
very  complicated.  The  subjective  sensations  of  the 
patient  arise  also  from  such  a  number  of  causes  that 
it  is  often  impossible  to  understand  how  they  are 
produced.  As  in  other  parenchymatous  organs,  no 
form  of  stimulation  of  the  lung  tissue  seems  to  be 
capable  of  producing  sensation  directly  or  reflexly. 


Affections  of  the  Lungs  and  Pleura.         205 

Below  the  epiglottis  there  is  no  sensation  elicited 
from  stimulating  the  air  passages,  though  coughing 
is  readily  induced  in  certain  regions.  The  lung 
itself  is  insensitive  to  stimulation  when  healthy  (as 
is  seen  when  an  exploring  needle  penetrates  the 
lungs)  or  when  diseased.  It  is  well  known  that  the 
lung  may  be  acuteh^  inflamed,  torn  by  an  apoplexy, 
ulcerated  and  scooped  out  by  a  tuberculous  process, 
and  no  sensation  be  felt  by  the  patient.  When  pain 
arises  in  connection  with  affections  of  the  lung,  it 
is  from  the  implication  of  the  pleura  in  the  disease 
process,  or  from  the  muscles  of  respiration  becoming 
sore  and  tender  from  excessive  exercise. 

Although  no  pain  arises  in  connection  with 
lung  affections,  other  sensations  appear,  as  the  sense 
of  breathlessness,  "  air  hunger,"  and  a  sense  of  suffo- 
cation. These  sensations  may  be  the  occasion 
of  acute  distress,  and  provoke  attempts  at  deep 
hispiration. 

Dr.  Haldane  considers  it  "  probable  that  '  air 
hunger '  is  always  due  to  excitation  of  the  respira- 
tory centre  in  consequence  of  an  abnornaal  condi- 
tion of  the  blood.  Nothing  else  is  known  to  produce 
'  air-hunger.'  The  excitation  may  be  due  to  (1)  excess 
of  COo.  This  is  the  normal  excitant.  The  excess  of 
CO.,  may  be  due  to  hindrance  to  entry  or  exit  of  air 
(asthma,  bronchitis,  etc.),  or  to  hindered  penetration 
of  CO2  from  the  blood  to  the  alveolar  air  (pneumonic 
or  dropsical  conditions  in  the  lung).  A  second  cause 
is  diminished  alkalinity  of  the  blood.  This  acts  just 
hke  CO2  on  the  centre.  A  typical  example  is  tlie 
liyperpncea  of  diabetic  coma  (oxy butyric  acid  in  the 
blood).  If  want  of  O,.  arises  in  the  tissues  from  hin- 
dered absorption  of  0^  by  the  lungs,  from  defective 


206  Chapter  XIX. 

circulation  (as  in  certain  forms  of  heart  failure) 
or  other  cause  (COo  poisoning,  poisoning  by  nitrites, 
or  other  substances,  which  disable  the  haemoglobin, 
etc.),  the  blood  also  becomes  less  alkaline  from  lactic 
acid  formation,  or  lactic  acid  is  formed  in  the  centre 
itself.  The  centre  is  thus  stimulated,  and  hyperpnoea, 
as  a  secondary  result  of  want  of  Oo,  results.  Want 
of  Oo  does  not  seem  to  be  a  direct  stimulus  to  the 
centre.  It  is  only  in  a  limited  number  of  cases  that 
pure  Oo  can  relieve  dyspnoea." 

112.  The  Respiration. — The  movements  of 
respiration  consist '  in  the  contraction  of  certain 
muscles,  increasing  the  size  of  the  chest  cavity,  and 
producing  the  inspiratory  act.  The  muscles  em- 
ployed in  the  act  of  respiration  are  the  diaphragm, 
the  external  intercostal  muscles,  the  levatores  cos- 
tarum,  and  serratus  posticus  superior.  As  these 
muscles  in  their  contraction  enlarge  the  cavity  of  the 
chest  by  raising  the  thorax  and  twisting  the  costal 
cartilages,  and  thus  stretch  the  elastic  tissue  of  the 
lungs,  so  when  they  cease  to  act  the  thorax  falls  by 
its  own  weight,  assisted  by  the  recoil  of  the  costal 
cartilao;es  and  of  the  elastic  tissues  of  the  luna^s.  The 
thoracic  cavity  is  thus  reduced,  and  the  air  is  ex- 
pelled. It  is  possible  that  the  internal  intercostal 
muscles  contract  with  each  expiration.  In  both  forced 
inspiration  and  expiration  a  large  number  of  acces- 
sory muscles  may  take  part  in  the  respiratory 
movements. 

Although  the  nerve  supplj^  of  these  muscles 
involved  in  respiration  come  from  widely  separated 
portions  of  the  cord,  they  are  all  under  the  dominance 
of  one  centre  in  the  medulla  oblongata  —  the 
respiratory    centre — the    noeud    vital    of     Flourens, 


Affections  of  the  Lungs  and  Pleura.         207 

situated  in  close  proximity  to  the  nuclei  of  the 
vagus  nerves. 

The  normal  rate  of  respiration  is  from  fourteen 
to  sixteen  per  minute,  when  the  body  is  at  rest. 
Abnormalities  are  usually  considered  from  the  stand- 
point of  increase  in  rate  and  violence  of  the  act  of 
respiration.  There  are,  however,  conditions  of  slow 
respiration,  apart  from  mechanical  obstruction, 
which  are  of  some  interest  as  thej^  are  associated 
with  certain  neurotic  conditions,  and  the  slow  re- 
spiration produces  a  form  of  heart  irregularity  (sinus 
arrh3'^thmia).  However  variable  the  rate.  Dr.  Haldane 
points  out  that  the  alveolar  ventilation  will  be  the 
same— the  frequent  breathing  being  shallow,  and  the 
slow  breathing  deep. 

Although  the  ph^^siology  of  respiration  so 
clearly  defines  the  method  by  which  respiration  is 
regulated,  3'et  there  is  nothing  so  perplexing  to 
explain  as  the  influences  that  operate  in  producing 
abnormal  forms  of  respiration.  In  any  given  case 
of  increased  frequency  of  respiration  it  is  difficult  or 
impossible  to  say  whether  the  condition  is  the  result 
of  imperfect  aeration  or  reflex  stimulation.  The 
presence  of  non-striped  muscle  fibres  in  the  smaller 
bronchi  leads  to  the  surmise  that  these  may  become 
tonically  contracted,  and  therefore  prevent  the 
entrance  of  air  to  the  alveoli. 

This  action  seems  all  the  more  probable  when 
we  reflect  that  asthma  is  so  often  the  outcome  of  a 
remote  stinaulation,  as  from  the  nasal  cavity,  and 
that  muscular  contraction  is  very  susceptible  to 
reflex  stimulation.  Dyspnoea  of  a  very  severe  form 
may  arise  from  pcriplieral  stimulation,  as  is  seen  in 
pneumonia,    or    pulmonary    apoplexy,    when    tlie 


208  Chapter  XIX. 

breathing  may  be  greatly  increased  in  frequency 
and  in  violence.  The  alteration  in  the  breathing  is 
not  the  outcome  of  a  diminution  of  the  breathing 
space  by  the  inflammatory  exudation,  or  apoplexy, 
for  the  rate  of  breathing  may  suddenly  return  to 
the  normal,  with  no  diminution  in  the  extent  of  the 
affection  of  the  lung.  Presumably  here  the  increased 
respiration  is  the  outcome  of  a  reflex,  but  whether 
the  stimulation  played  directly  upon  the  respiratory 
centre,  or  whether  it  caused  a  reflex  spasm  of  the 
bronchial  muscles,  we  cannot  tell.  The  dyspnoea 
arising  from  other  sources  is  equally  obscure.  Dr. 
Haldane  considers  "  the  respiratory  trouble  in  heart 
failure  to  be  due  (at  least  mainly)  to  the  slowed  cir- 
culation, and  consequent  imperfect  aeration  of  the 
tissues.  The  deficiency  of  0.  in  the  tissues  will  cause 
increased  formation  of  lactic  acid,  and  consequent 
diminished  alkalinity  of  the  blood,  and  consequent 
necessity  for  an  abnormally  great  removal  of  CO2 
from  the  blood.  The  increased  respirations  may  also 
materially  assist  the  circulation  by  aspirating  more 
venous  blood  towards  the  heart.  The  breathless 
healthy  person  is  breathless  from  excess  of  CO.,  in 
the  arterial  blood.  In  heart  disease  there  is  no  ex- 
cess of  CO2,  or  deficiency  of  0^  in  the  arterial  blood, 
but  this  condition  exists  in  the  tissues  owing  to  the 
slow  circulation.  Slight  hyperpnoea  will  diminish 
the  CO 2  in  the  arterial  blood,  and  thus  compensate 
for  excess  of  CO2 ;  but  hyperpnoea  cannot  appreci- 
ably increase  the  oxygen  in  the  arterial  blood,  and 
therefore  cannot  compensate  for  the  want  of  0.,  in 
the  tissues.  The  patient  is  therefore  blue,  although 
his  breathing  may  not  be  noticeably  increased.  Exer- 
tion   during    any    condition    where   the    circulation 


Affections  of  the  Lungs  and  Pleura.         209 

(particularly  in  the  coronary  vessels)  is  defective,  and 
cannot  be  increased  in  response  to  the  increased  need 
for  blood,  will  lead  to  a  fall  of  blood  pressure,  the 
heart  being  incapable  of  supplying  enough  blood  to 
correspond  to  the  increased  flow  (vaso-dilatation)  in 
the  working  muscles.  Fainting  will  thus  be  caused. 
The  same  effect  is  seen  in  CO 2  poisoning,  where  even 
a  slight  exertion  produces  fainting  with  absolute 
certainty,  and  may  be  fatal." 

113.  Reflex  Symptoms. —  Cough. — Coughing  is 
essentially  a  reflex  phenomenon,  the  centre  for  which 
is  one  of  the  numerous  areas  associated  with  the 
main  respiratory  one  in  the  bulb.  The  stimulus  is 
conveyed  from  the  periphery  by  some  branch  of  the 
vagus.  The  result  of  the  stimulus  is  to  cause  first  a 
deep  inspiration,  which  is  followed  by  a  closure  of 
the  glottis,  then  by  a  sudden  and  powerful  contrac- 
tion of  the  muscles  of  expiration  which  forces  the  air 
through  the  resisting  glottis.  By  this  process  the  air 
drawn  into  the  lungs  by  the  prelimmary  inspiration 
is  driven  out  with  such  force  that  all  movable  matter 
in  the  larger  tubes  is  swept  out.  The  area  that  most 
readily  excites  the  cough  reflex  is  the  mucous  mem- 
brane of  the  larynx,  the  nerve  supply  being  from 
the  superior  laryngeal  nerve,  a  branch  of  the  vagus. 
The  respiratory  tract  below  the  larynx  and  the  lung 
tissue  seem  to  be  incapable  of  originating  the  stimu- 
lus. The  cough  in  affections  of  the  lung  arises  only 
\\lion  the  secretion  has  been  carried  by  the  contrac- 
tions of  the  bronchial  muscles,  and  by  the  cilia  of 
the  respiratory  tract  so  far  upward  as  to  reach  the 
sensitive  region  about  the  hirynx.  Thus  it  is  that  in 
pneumonia  the  cough  may  be  only  slight,  and  only 
provoked   when   the   secretion   has   passed   up    tlie 


210  Chapter  XIX. 

respiratory  tube.  In  phthisis  and  abscess,  and  all 
cases  where  there  is  abundant  expectoration,  it  is  to 
be  noted  that  the  starting  of  a  cough  after  a  period 
of  quiescence  is  followed  by  a  persistence  until  the 
accumulated  matter  is  expelled.  The  first  cough 
is  initiated  by  the  gradual  conveyance  of  the  phlegm 
to  the  sensitive  area,  while  afterwards  the  cough  for- 
cibly expels  the  contained  matter,  and  so  keeps  up 
the  irritation  until  there  ceases  to  be  forced  out  any 
more  secretion.  This  sensitive  region  may  be  stimu- 
lated by  the  inhalation  of  cold  air,  and  it  seems  to 
be  the  starting  place  of  the  spasm  of  uncontrollable 
coughing  in  whooping-cough.  While  this  is  prob- 
ably the  true  explanation  of  the  great  majority  of 
cases,  coughing  can  also  be  excited  by  stimulation  by 
other  means.  When  a  pleuritic  effusion  is  aspirated, 
scratching  the  visceral  pleura  will  often  produce  a 
cough,  or  irritation  of  the  branches  of  the  vagus  that 
go  to  the  stomach  or  ear  may  produce  coughing.  It 
is  always  well  to  exclude  the  possibility  of  irritation 
in  the  larynx,  before  assuming  the  presence  of  the 
more  remote  stimulation.  A  very  curious  cough  re- 
flex is  sometimes  present  in  persons  who  have  an 
occasional  extra-systole.  This  is  usually  due  to  the 
ventricle  contracting  prematurely  before  the  auricle, 
and  the  individual  may  be  conscious  of  this,  and  may 
give  at  the  same  time  a  short  cough — without  the 
preliminary  inspiration.  In  hysteria  violent  and 
persistent  coughing  may  occur  either  from  a  trivial 
laryngeal  irritation,  or  it  may  be  in  consequence  of 
some  other  reflex  irritation. 

Sneezing. — A  reflex  of  a  somewhat  similar 
nature  to  that  of  coughing  arises  from  stimulation 
of  the  mucous  membrane  of  the  nose.   It  differs  from 


Affections  of  the  Lungs  and  Pleura.         211 

a  cough,  inasmuch  as  there  is  no  closure  of  the  glottis, 
and  the  blast  of  air  is  sent  through  the  nose  as  well 
as  the  mouth.  It  also  differs  from  the  act  of  cough- 
ing in  always  being  a  pure  rellex.  Coughing  can  be 
done  voluntarily,  but  sneezing  cannot.  Sneezing  can 
be  inhibited  bj^  biting  the  upper  lip,  or  pinching  the 
edge  of  the  nasal  bones,  even  after  the  preliminary 
inspiration,  and  by  a  mental  reaction,  as  when  an- 
other person  is  observed  to  imitate  the  act. 

Persistent  attacks  of  sneezing  are  commonly 
associated  with  a  swelling  of  the  erectile  tissue  over 
the  turbinate  bones  in  the  nose,  and  a  free  secretion 
from  the  mucous  membrane  of  the  nose  and  ej'es. 

114.  Functional  Symptoms. —  Aeration  of  the 
blood. — Impaired  function  is  seen  in  the  degree  of 
aeration  of  the  blood,  and  in  the  character  of  the 
expectoration.  Aeration  of  the  blood  is  the  main 
function  of  the  lungs,  and  imperfect  aeration  is 
manifested  in  the  production  of  the  reflex  phenomena 
(air-hunger,  increased  respiratory  movements)  and 
in  the  colour  of  the  blood.  The  former  of  these 
symptoms  has  already  been  discussed  ;  the  latter  is 
observed  mainly  in  an  abnormal  colour  of  the 
external  tissues,  as  in  the  lips,  cheeks,  or  skin 
generally. 

As  witli  all  other  respiratory  symptoms,  the  pro- 
duction of  the  signs  of  imperfectly  aerated  blood  is 
obscure  and  complicated.  The  face  may  show  a 
slight  degree  of  duskiness,  the  redness  be  a  little 
darker  than  that  of  health,  or  the  redness  of  the  Hps 
a  little  deeper  in  cases,  say,  of  mitral  stenosis.  Blue- 
ness  of  the  lips  may  be  due  to  imperfect  aeration  of 
the  blood  in  the  lungs,  but  it  also  may  be  due  to 
slowing  of  the  circulation.     It  is  remarkable  how 


212  Chapter  XTX. 

much  darker  the  venous  blood  becomes  if  the  rate 
of  flow  through  the  capillaries  be  diminished.  This 
is  probably  the  cause  of  the  cyanosis  in  congenital 
heart  disease.  In  some  cases  there  has  been  found 
a  great  increase  in  the  number  of  red  blood  cor- 
puscles, and  a  certain  degree  of  duskiness  is  found 
in  cases  of  polycj^themia.  Where  there  is  a  duskiness 
due  to  some  permanent  condition  as  polycythemia,  or 
the  cyanosis  of  congenital  heart  disease,  exertion 
often  increases  the  depth  of  the  cyanosis. 

In  failing  hearts,  with  embarrassment  of  the 
pulmonary  circulation,  a  very  considerable  duskiness 
may  be  evident,  as  also  in  cases  where  there  is  ob- 
struction to  the  entrance  of  air  into  the  lungs.  As 
the  heart  is  exceedingly  susceptible  to  oxygen, 
imperfect  aeration  of  the  blood  has  a  very  marked 
effect  upon  ifc,  a  diminished  supply  of  oxygen  acting 
speedily  in  stopping  its  action,  and  in  the  adminis- 
tration of  chloroform  this  is  one  of  the  most  impor- 
tant facts  to  be  borne  in  mind. 

Expectoration. — Expectoration  is  the  product 
of  perverted  function,  and  may  be  due  to  a  secretion 
of  the  respiratory  tract  or  lungs.  It  may  also  come 
from  regions  outside  the  lungs,  as  when  an  abscess 
or  pleural  effusion  bursts  into  the  lungs,  or  bronchi. 
It  is  the  most  frequent  cause  of  cough,  and  coughing 
is  due  to  the  attempt  to  get  rid  of  the  secretion.  The 
expectoration  is  conveyed  in  the  first  place  by  the 
contraction  of  the  bronchial  muscles,  and  by  the  cilia 
of  the  respiratory  tract  to  the  bronchial  tubes,  till 
an  excitable  part  is  reached,  when  coughing  is  in- 
duced, and  the  blast  of  air  expels  the  accumulated 
secretion.  The  force  exercised  in  compressing  the 
chest  helps  to  expel  secretion  accumulated  in  an}^ 


Affections  of  the  Lungs  and  Pleura.         213 

part  of  the  respiratory  tract,  or  in  the  lungs  and 
pleural  cavity,  so  long  as  there  is  an  exit. 

The  character  of  the  expectoration  indicates  its 
source,  a  transparent  and  froth}^  expectoration  com- 
ing from  the  upper  air  passage,  while  the  more  viscid 
comes  from  the  lower,  or  from  near  the  alveoli,  as  in 
the  early  stages  of  pneumonia,  when  it  is  usually 
stained  more  or  less  deeply  with  blood.  A  clear, 
pink-stained  mucus  may  result  from  a  pulmonary 
apoplexy.  A  purulent  sputum  is  due  to  a  lesion  of 
some  standing.  In  bronchitis  the  sputum  gradually 
changes  from  a  mucous  to  a  muco-purulent  character. 
An  abundant  muco-purulent  sputum  is  found  in 
chronic  bronchitis  and  old  standing  catarrhal  pneu- 
monia. With  an  excess  of  fever,  the  latter  conditio]! 
may  resemble  an  attack  of  acute  croupous  pneu- 
monia, but  the  abundant  purulent  secretion  serves 
to  indicate  the  nature  of  the  illness.  The  secretion 
from  phthisical  cavities  is  also  purulent.  When 
large  quantities  of  pus  are  expectorated,  the  source 
is  a  cavit}^  in  the  lungs  or  pleura,  or  a  subphrenic 
abscess,  as  a,  suppurating  h\'datid  cj'st  of  the  liver. 

The  microscopic  examination  for  bacilli  and 
elastic  fibres  is  fully  detailed  in  text-books. 

115.  Structural  Symptoms. — Structural  symp- 
toms are  recognised  by  changes  in  the  consistence  of 
the  lung  tissue,  in  the  invasion  of  the  normal 
resonant  area  by  structures  of  more  solid  consistence, 
changes  in  the  shape  of  the  chest  wall,  and  the 
presence  of  accessory  sounds  or  the  modification  of 
the  normal  respiratory  sounds  in  auscultation.  It 
is  not  my  purpose  to  enter  into  the  details  of  these 
changes,  and  I  merely  point  out  here  that  the  exist- 
ence of  any  abnormal  state  can  only  be  ascertained 


214  Chapter  XIX. 

by  thorough  knowledge  of  the  normal  condition  of 
the  lungs.  The  position  of  the  lungs  in  relation  to 
other  organs,  the  modification  of  the  signs  of  the 
lung  in  the  different  regions  of  the  chest,  should  all 
be  famihar  through  the  systematic  examination  of 
a  great  number  of  healthy  people.  In  all  these  ob- 
servations, and  more  particularly  in  the  examination 
of  abnormal  or  diseased  lungs,  the  recognition  of  the 
abnorm.al  signs  depends  on  the  comparison  of  the 
signs  in  one  individual  with  another,  or  in  the  com- 
parison of  the  signs  on  opposite  sides  in  the  indi- 
vidual examined.  As  there  are  infinite  gradations, 
it  requires  careful  training  to  recognise  many  of  the 
more  delicate  but  none  the  less  very  important 
phenomena. 

116.  Affections  of  the  Pleura. — Insensitiveness 
of  the  Pleura. — If  the  affection  of  the  lung  gives 
rise  to  no  sensation  of  pain,  the  same  cannot  be  said 
of  the  pleura,  for  the  pains  associated  with  pleurisy 
may  be  of  the  most  violent  kind.  In  consequence  of 
this  well-recognised  fact,  the  pleura  is  supposed  to 
be  an  extremely  sensitive  structure,  though,  as  a 
matter  of  fact,  it  is  as  insensitive  as  the  peritoneum 
to  ordinary  stimulation.  In  a  great  number  of  cases, 
when  the  ribs  have  been  resected,  I  have  repeatedly 
explored  the  pleural  cavity  for  any  evidence  of  sen- 
sation, and  I  could  employ  no  form  of  stimulation 
capable  of  producing  pain.  When  I  probed  the  vis- 
ceral pleura,  even  to  penetrating  the  lung,  no  sensa- 
tion was  produced  ;  when  I  scraped  the  surface  of 
the  parietal  pleura  no  sensation  was  produced,  unless 
I  pressed  with  some  force,  when  a  vague  sensation 
was  experienced,  due  probably  to  the  pressure  being 
exercised  on  the  structures  of  the  external  body  wall. 


Affections  of  the  Lungs  and  Pleura.         215 

117.  Nature   of   the   Pain   in    Pleurisy. — From 

the  result  of  such  experience  one  is  forced  to  con- 
sider carefully  how  the  great  pain  felt  in  pleurisy  is 
produced.  Inquiry  into  the  nerve  supply  of  the 
pleura  is  fruitless,  for  there  is  practically  no  inform- 
ation about  the  matter  in  either  anatomical  or 
physiological  text-books.  Although  I  carried  out  a 
series  of  careful  dissections  of  intercostal  nerves  to 
their  finest  branches,  I  could  detect  none  entering  the 
pleura.  Whether  there  is  a  laj^er  containing  fine 
nerve  endings  outside  the  pleura  similar  to  that 
described  by  Ramstrom  lying  outside  the  peritoneum, 
I  do  not  know.  A  careful  study  of  all  the  phenomena 
connected  with  a  painful  pleurisy  reveals  the 
mechanism  by  which  it  is  produced,  and  gives  some 
indication  of  its  nerve  suppty.  The  most  severe  pain 
occurs  in  the  movements  of  respiration,  and  is  due  to 
the  painful  contraction  of  the  intercostal  muscles.  In 
the  abdominal  muscles  the  muscular  hyperalgesia 
and  tonic  contraction  can  be  demonstrated.  It  is  not 
so  easy  to  do  this  in  the  case  of  the  intercostal  mus- 
cles, but  there  is  good  reason  for  inferring  that  the 
viscero-motor  reflex  is  as  definite  in  pleuritis  as  in 
peritonitis. .  The  muscles  are  often  tender  on  pres- 
sure, and  their  contraction  is  not  only  painful  but 
ends  in  a  spasm  which  restrains  the  movements  of 
the  chest.  The  symptoms  of  pain  and  violent  con- 
traction are  identical  with  those  that  occur  when 
the  muscle  is  hyperalgesic,  apart  from  a  pleurisy,  as 
in  the  painful  contraction  of  the  intercostal  muscles 
in  "  muscular  rheumatism,"  and  in  those  cases  where 
the  hyperalgesia  extends  into  the  cliest  wall  from 
affections  of  other  viscera,  as  in  gall-stone  disease 
(see  page  160). 


216 


Chapter  XIX. 


Fig.  15. 


Areas  in  which  pain  and  hyperalgesia  were  present  in  a  case  of 
diaphragmatic  pleurisy.  The  shaded  area  on  the  left  shoulder  is  in  the 
cutaneous  distribution  of  the  fourth  cervical  nerve,  and  is  an  evidence 
of  the  conduction  of  a  stimuhis  from  the  diaphragm  by  the  phrenic  nerve, 
which  leaves  the  sjjinal  cord  with  the  fourth  cervical  nerve.  The  phrenic 
nerve  contains  afferent  fibres  as  well  as  efferent  (motor),  and  it  is  in  all 
probability  by  the  former  that  the  stimulus  is  conveyed  to  the  centre  of 
the  fourth  cervical  nerve  in  the  cord.  The  shaded  area  in  the  abdomen 
is  in  the  region  of  distribution  of  the  8th  and  9th  thoracic  nerves. 


Affections  of  the  Lungs  and  Pleura.         217 

The  mechanism  of  the  pain  can  also  be  inferred 
from  those  cases  in  which  it  is  felt  at  a  distance 
from  the  inflamed  pleura.  When  the  diaphragm- 
atic pleura  is  inflamed  the  pain  may  be  felt  in  two 
regions  very  widely  separated,  namely,  in  the  abdo- 
men below  the  ribs  and  on  the  top  of  the  shoulder. 
(Fig.  15.) 

It  not  infrequently  happens  that  the  onset  of 
pneumonia  is  accompanied  by  a  severe  pain  in  the 
abdomen,  and  the  skin  in  the  region  where  the  pain 
is  felt  may  be  found  extremely  hyperalgesic.  (Not 
infrequently,  and  particularly  in  the  3^oung,  this  pain 
misleads  in  the  diagnosis,  giving  the  impression  that 
some  abdominal  viscus  is  at  fault.)  The  area  in 
which  this  hyperalgesia  is  found  is  within  the  peri- 
pheral distribution  of  the  eighth  and  ninth  thoracic 
nerves.  I  have  no  distinct  proof  that  in  such  cases 
the  pain  and  hyperalgesia  are  due  to  pleurisy,  and 
not  to  the  lung  affection,  except  for  the  very  common 
•experience  that  the  inflammation  of  the  lung  is  pain- 
less, while  inflammation  of  the  pleura  is  usuaU}^ 
associated  with  pain,  and  the  hyperalgesia  may  be 
detected  in  basal  pleurisies  without  pneumonia.  It 
is  evident  that  there  must  be  some  correlation 
between  the  lesion  and  the  area  of  hyperalgesia,  and 
as  no  nerve  from  the  region  of  the  eighth  or  ninth 
thoracic  nerves  supphes  the  lungs,  it  is  reasonable 
to  conclude  that  the  nerve  supply  from  the  inflamed 
pleura  must  be  from  this  region.  The  pain  felt  in 
the  shoulder  is  more  instructive.  It  is,  however,  a 
somewhat  rare  phenomenon,  but  in  the  few  cases  I 
have  seen  in  which  there  has  been  cutaneous  hyperal- 
gesia, the  area  could  be  marked  out  very  distinctly, 
and  was  found  to  be  within  tlie  distribution  of  the 


218  Chapter  XIX. 

fourth  cervical  nerve.  I  have  already  dealt  some- 
what fully  with  the  distribution  of  the  phrenic  nerve 
and  its  relation  to  the  fourth  and  fifth  cervical  nerve 
{see  page  48).  Its  distribution  being  to  the  dia- 
phragm, and  not  to  the  lungs,  permits  of  the  reason- 
able inference  that  the  pain  and  hyperalgesia  in  the 
shoulder  found  associated  with  pneumonia  are  due 
to  the  pleurisy  and  not  to  the  pneumonia. 

From  the  consideration  of  these  facts  we  can 
draw  the  inference  that  the  pain  in  pleurisy  is  due 
to  a  reflex  stimulation  (viscero-sensory  reflex),  and 
that  as  there  arises  also  a  hyperalgesia  of  the  inter- 
costal muscles,  their  contraction  is  not  only  painful, 
but  their  continued  exercise  increases  the  violence 
and  painfulness  of  their  contraction.  As  happens  in 
all  muscles  affected  by  a  visceral  stimulus  (viscero- 
motor reflex),  there  is  a  great  tendency  with  exercise 
for  the  muscle  to  be  tonically  contracted,  and  hence 
the  constrained  and  limited  movements  of  the  chest 
wall  present  in  pleurisy. 


(     219     ) 


CtT  AFTER    XX. 

AFFECTIONS     OF     THE     CIRCULATORY 
SYSTE:\r. 

118.  Heart  Failure. 

119.  The  Nature  of  the  Symptoms  in  Heart  Failure. 

120.  Consciousness  of  the   Hearfs    Action. 

121.  Breathlessness. 

122.  Viscerosensory  and    Viscero-motor   Reflexes. 

123.  The    Viscerosensory  Reflexes  in  Dilatation  of 

the  Heart  and  Liver. 

124.  The  Pain  of    Angina  Pectoris  is  a    Viscero- 

sensory Reflex. 

125.  Evidences  of  the    Viscero-motor  Reflex. 

126.  Organic  Reflexes. 

127.  Summation  of  Stimidi   the   cause  of    Angina 

Pectoris. 

There  is  no  system  in  the  body  whose  function 
can  be  so  well  observed,  and  whose  size  and  position 
can  be  better  made  out,  than  that  of  the  circulatory 
system.  As  a  consequence  of  this  accessibility  the 
circulatory  apparatus  has  received  a  great  deal  of 
attention,  and  innumerable  methods  are  employed 
in  the  investigation  of  its  action.  The  value  of  many 
of  these  methods  is  unquestioned,  but  unfortunately 
the  tendency  has  been  to  place  undue  reliance  on 
the  results  obtained  by  mere  physical  examination, 


220  Chapter  XX. 

and  to  neglect  the  more  important  indications  to  be 
derived  from  the  reflex  phenomena,  chiefly  expressed 
in  the  sensations  felt  by  the  patient. 

118.  Heart  Failure. — In  order  to  realise  fully 
the  meaning  of  cardiac  symptoms,  it  is  necessary  to 
appreciate  the  mechanism  of  heart  failure.  By 
heart  failure  is  meant  the  inability  of  the  heart  to 
maintain  the  circulation  efficiently.  The  lack  of 
efficiency  may  be  made  evident  in  extreme  cases  by 
such  signs  as  orthopnoea,  dropsy,  unconsciousness.  On 
the  other  hand,  the  failure  of  the  heart  to  maintain 
an  efficient  circulation  may  be  manifest  long  before 
these  extreme  S37mptoms  appear.  The  first  sign  is 
a  feeling  of  distress  when  the  patient  makes  an 
effort.  This  may  vary  within  very  wide  limits  ;  for 
instance,  turning  over  in  bed  may  exhaust  the 
heart's  strength,  or  the  patient  may  be  unable  to 
walk  across  the  room,  or  up  a  flight  of  stairs, 
without  some  form  of  discomfort  checking  him. 
The  exhaustion  of  the  patient's  strength  in 
such  circumstances  is  seen  simply  as  a  limitation 
of  the  heart's  power  to  respond  to  effort.  Each 
individual  has  become  accustomed  to  what  he 
can  do  with  comfort,  and  he  recognises  his  heart 
failure  by  not  being  able  to  exert  himself  with  com- 
fort to  the  extent  he  had  formerly  done.  The 
symptoms  produced  in  health  by  over-exertion  are 
frequently  identical  with  those  produced  by  slight 
exertion  when  the  heart  has  become  weakened  and 
where  this  slight  exertion  is  more  than  can  be  done 
with  comfort.  It  will  thus  be  seen  that  the  symptoms 
of  heart  failure  are  really  recognised  by  a  limitation 
of  the  field  of  cardiac  response,  that  is,  the  patient 
finds  he  is  stopped,   on  a  slight  exertion,   by  the 


Affections  of  the  Circulatory  System.        221 

symptoms  which,  when  in  health,  only  stopped  him 
after  a  prolonged,  exhausting  exertion. 

This  weakness  of  the  heart  can  be  expressed  in 
another  wa}^  namely,  the  premature  exhaustion  of 
reserve  force.     It  is  because  the  heart  possesses  the 
power  to  lay  up  a  reserve  of  force  that  it  is  able  to 
respond  to  calls  on  its  energy,  so  that  it  can  accommo- 
date itself  to  the  varying  activities  of  the  body. 
When  the  body  is  at  rest  the  heart  not  only  over- 
comes the  resistances  opposed  to  its  work  with  ease, 
employing  only  a  portion  of  its  power,  but  it  is  at 
the  same  time  building  up  a  store  of  energy  ready 
to  be  hberated  when  the  next  call  is  made  by  the  body 
for  more  work.     After  severe  bodily  labour  the  store 
of   reserve    forces    become    exhausted,    and   if   the 
labour  be  persisted  in,  there  arises  a  feeling  of  dis- 
tress, which  expresses  the  exhaustion  of  the  heart's 
reserve  force.     It  is  this  facultj^  of  building  up  a 
sufficient  reserve  store  that  distinguishes  a  healthy 
heart  from  a  weakened  heart,  and  the  first  evidence 
of  weakness  is  shown  by  a  too  speedy  exhaustion  of 
the  reserve.     This  is  made  evident  by  distress  being 
aroused  when  the  individual  undertakes  some  form 
of  exertion  he  had  been  wont  to  do  with  ease — that 
is,  by  a  limitation  of  the  field  of  cardiac  response. 

It  will  thus  be  seen  that  the  sj^mptoms  of  heart 
failure  in  the  first  instance  arc  personal,  due  to  the 
patient's  recognition  of  his  limitations.  The  estimate 
is  therefore  a  very  variable  one,  and  depends  on  each 
individual  recognising  his  own  limitations,  and 
detecting  when  these  limitations  become  narrowed. 
Each  individual  obtains  a  fair  estimate  of  his  power 
of  exertion,  and  this  is  his  measure  of  health.  A 
limitation  of  these  powers  in  an  intelligent  patient 


222  Chapter  XX. 

calls  attention  to  his  condition.  It  will  further 
be  observed  that  the  main  symptoms  of  exhaustion 
of  reserve  force  are  the  same  when  a  healthy  heart 
exhausts  its  store  after  a  prolonged  effort  as 
when  an  enfeebled  or  diseased  heart  exhausts  its 
limited  store  by  a  slight  effort.  These  symptoms  are 
in  the  main  subjective  and  reflex,  though  certain 
changes  may  also  be  made  out  in  the  size  of  the  heart 
and  its  rate  and  rhythm.  It  is,  however,  the  sub- 
jective and  reflex  symptoms  that  are  of  the  greatest 
importance,  whatever  may  be  the  nature  of  the  func- 
tional disorder  or  structural  lesion. 

It  will  frequently  be  found  that  patients  whose 
hearts  show  many  forms  of  functional  and  structural 
abnormalities  (valvular  murmurs,  cardiac  enlarge- 
ment, irregular  action)  have  such  a  store  of  reserve 
force  that  they  can  pursue  laborious  occupation 
with  ease  and  comfort,  and  live  to  a  good  age.  On 
the  other  hand,  patients  may  show  no  physical  sign 
of  abnormality  ;  the  heart  may  be  normal  in  size 
and  in  rate,  and  regular  in  rhythm,  and  the  sounds 
be  clear  and  free  from  murmur  ;  but  the  reserve  force 
be  so  small  that  the  slightest  exertion  entails  at  once 
distressful  symptoms  of  heart  exhaustion,  and  the 
lives  of  these  persons  may  be  very  precarious. 

119.  The  Nature  of  the  Symptoms. — The  value 
of  symptoms  thus  depends  upon  the  estimation  of 
the  amount  of  reserve  force  stored  up  in  the  heart 
muscle.  An  imperfect  valvular  apparatus  is  but  an 
embarrassment  to  the  heart  muscle  in  its  work.  We 
can  detect  that  valvular  imperfection  by  the 
presence  of  a  murmur,  but  we  can  only  draw  a  very 
limited  conclusion  as  to  its  bearing  on  the  heart's 
AYork.     This  is  really  obtained  hy  considering  the 


Affections  of  the  Circulatory  System.        223 

amount  of  reserve  force,  and  the  estimation  of  the 
reserve  is  made  by  observing  how  the  patient's  heart 
responds  to  effort.  The  same  rule  applies  to  other 
forms  of  circulatory  changes,  as  affections  of  the 
myocardium  and  of  the  arterial  S3^stem.  When, 
therefore,  we  detect  what  we  consider  to  be  an 
abnormal  sign,  we  must  not  draw  our  conclusions 
from  that  sign  alone,  but  must  consider  how  far  its 
cause  has  proved  an  impediment  to  the  heart's  action, 
and  this  is  done  by  estimating  the  amount  of  reserve 
force.  In  doing  this  a  wise  discretion  must  be 
exercised,  for  other  factors  may  have  precipitated 
the  exhaustion.  An  individual  may  have  an  organic 
lesion,  as  a  valvular  defect,  but  in  addition  may 
have  been  subjected  to  a  life  that  predisposes  to 
exhaustion,  as  excessive  labour,  improper  or  insuffi- 
cient food,  mental  anxiety,  sleeplessness,  infections, 
diseases  of  other  organs  ;  and  such  factors,  rather 
than  the  mere  valvular  flaw,  may  be  the  actual  cause 
of  the  exhaustion  of  the  reserve  force.  Or  the 
individual  may  have  a  sedentary  occupation,  wherein, 
owing  to  lack  of  judicious  exercise,  his  reserve  force 
has  gradually  diminished,  until  some  unaccustomed 
but  not  excessive  effort  calls  attention  to  the  limited 
field  of  cardiac  response. 

Not  only  must  a  careful  calculation  be  made  of 
these  accessory,  and  it  may  be  all-important,  factors, 
but  there  must  be  a  recognition  of  the  significance 
of  the  cardiac  abnormalities  or  supposed  abnor- 
malities. I  do  not  enter  here  on  the  points  which 
indicate  tlie  nature  and  seriousness  of  such  abnor- 
malities as,  for  instance,  murmurs  and  heart 
irregularities,  but  I  wish  to  insist  upon  the  fact  that 
llie   clinician   should   familiarise   himself   with   such 


224  Chapter  XX. 

points.  For  instance,  a  young  person  may  have 
a  fainting  attack,  and  when  lying  quietly  in  bed 
the  pulse  is  found  very  irregular.  This  sign,  which 
is  a  perfectly  normal  one,  though  rarely  recognised 
as  such,  is  not  infrequently  linked  up  with  the 
fainting  attack,  with  which,  as  a  matter  of  fact,  it 
has  no  connection,  and  the  patient  is  subjected  to 
unnecessary  treatment  and  restriction,  and  he 
becomes  alarmed  by  the  idea  that  he  has  a 
weak  or  diseased  heart.  In  advanced  life 
another  form  of  irregularity  is  of  extreme 
frequency  (the  extra-systole),  and  the  recogni- 
tion of  its  presence,  with  some  limitation  of 
the  field  of  cardiac  response,  often  leads  to  the 
conclusion  that  the  irregularity  is  in  some  way 
responsible  for  the  other  cardiac  signs,  and  energetic 
but  futile  means  are  taken  in  the  attempt  to  cure 
the  irregularity.  In  the  same  way  this  morbid 
dread  of  the  unknown  leads  to  the  idea  that  certain 
cardiac  symptoms  as  pain,  especially  when  dignified 
by  the  term  of  angina  pectoris,  is  of  very  grave 
significance.  If  it  be  once  realised  that  pain  is  as 
constant  a  symptom  in  affections  of  the  heart  as  in 
other  hollow  muscular  organs,  and  that  the  pain  is 
as  readily  induced  by  adequate  causes  in  the  heart 
as  in  the  stomach,  a  truer  perception  will  be  obtained 
of  the  symptoms  of  many  obscure  heart  affections. 
I  shall  show  later  that  pain  is  one  of  the  expressions 
of  an  exhausted  heart  muscle,  and  in  order  to 
appreciate  its  significance  the  conditions  that  have 
led  up  to  the  exhaustion  of  the  heart  muscle  should 
be  ascertained — a  matter  usually  of  no  great 
difficulty — and  these  conditions  will  guide  us  to  a 
safe  conclusion. 


Affections  of  the  Circulatory  System.        225 

If  the  idea  be  followed  up  that  the  earliest  of 
heart  symptoms  are  simply  due  to  an  exhaustion  of 
the  store  of  reserve  force,  it  will  be  found  that  there 
is  a  great  resemblance  in  the  reflex  symptoms 
among  all  forms  of  heart  affections — functional  and 
structural.  The  most  important  symptoms  are 
confined  mainly  to  the  patient's  sensations  and 
demand  careful  consideration.  The  mechanism  by 
which  they  are  produced  is  not  at  all  times  clear, 
and  some  of  them  are  undoubtedly  reflex  ;  although 
I  cannot  give  a  full  explanation  of  their  production, 
I  attempt  here  a  brief  description  of  the  most  im- 
portant of  the  subjective  symptoms  and  some  of 
the  phenomena  associated  with  them. 

120.  Consciousness  of  the  Heart's  Action. — 
Under  normal  circumstances  the  movements  of 
the  heart  and  circulation  are  carried  on  without 
the  individual  being  conscious  of  their  action 
unless  he  voluntarily  directs  his  attention  to  the 
subject.  When  the  heart  is  over-stimulated  it  may 
contract  with  such  force  that  the  individual 
becomes  conscious  of  its  action.  The  stimula- 
tion may  arise  from  a  great  many  circumstances, 
as,  for  instance,  from  heat,  either  by  a  rise 
in  the  patient's  temperature  or  from  a  hot  bath. 
It  may  arise  from  nerve  stimulation,  as  from  mental 
excitement,  or  from  some  peripheral  irritation  in 
the  viscera.  Its  significance  is  greatest  when  it 
arises  in  consequence  of  exhaustion  of  the  heart ; 
coming  on  in  consequence  of  bodily  exertion,  it 
is  often  btie  first  sign  of  exhaustion  of  the  reserve 
force.  When  it  is  thus  produced,  it  forms  a  valuable 
sign  for  estimating  the  amount  of  reserve  force 
present  in  the  heart-muscle.     It  gives  no  indication 

Q 


226  Chapter  XX. 

of  the  conditions  that  have  led  to  this  exhaustion, 
for  it  ma}^  occur  in  a  healthy  heart  after  prolonged 
exertion,  as  well  as  in  a  diseased  hea,rt  after  a  very 
slight  exertion.  Under  these  circumstances  the 
heart's  action  is  usually  rapid  as  well  as  forcible, 
but  in  some  cases  there  is  not  much  increase  in 
rate.  The  consciousness  of  the  heart's  action  is 
often  spoken  of  as  palpitation.  While  it  may  not 
occasion  much  suffering,  there  are  individuals  of  a 
neurotic  type  in  whom  this  consciousness  of  the 
heart's  action  causes  much  distress.  In  these 
patients  the  heart  may  be  quite  healthy,  and  the 
palpitation  is  then  the  action  of  an  undue  excita- 
bility of  the  sympathetic  nerve  supply  of  tlie  heart. 
As  other  portions  of  the  nervous  system  are  abnor- 
mally excitable  the  heart's  action  may  cause  con- 
siderable distress  bodily  and  mentally.  In  patients 
with  this  neurotic  temperament,  where  there  is  real 
heart  trouble,  as  in  mitral  stenosis,  palpitation  on 
exertion  may  be  so  readily  induced  that  it  acts  as  a 
protection  from  over-exertion,  because,  in  order  to 
avoid  its  occurrence,  the  patient  is  perforce  kept 
quiet. 

The  occurrence  of  palpitation  should  always 
lead  to  an  examination  of  the  nervous  system  as  well 
as  of  the  heart's  condition. 

Other  sensations  of  the  heart's  abnormal  action 
may  be  felt  by  the  patient.  A  gentle  fluttering 
may  be  felt  within  the  chest  during  a  period  of 
irregular  action.  This  may  be  brief  and  transient, 
or,  as  in  certain  cases  of  paroxysmal  tachycardia,  it 
may  continue  during  an  attack  of  many  hours. 
Accompanying  the  latter  condition  there  is  often  a 
feeling   of   exhaustion   wliich   leads   the   patient   to 


Affections  of  the  Circulatory  System.         227 

rest,  or  to  go  about  carefully  and  quietty.  When 
the  heart  resumes  its  normal  action  the  patient  is 
at  once  conscious  of  a  change  and  of  a  sense  of 
relief.  A  more  common  sensation  is  that  when 
the  heart  is  felt  to  stand  still,  in  what  is  called 
intermittent  action  of  the  heart.  This  sensation  is 
usually  felt  in  cases  of  extra-systole,  which  is  so 
frequent  in  advanced  life  though  occasionally 
present  in  the  young.  Here  the  ventricle  con- 
tracts prematurely,  and  often  before  the  auricle  ; 
the  individual  is  not  conscious  of  this  premature 
beat  or  extra-sj^stole  which  is  followed  by  a  long- 
pause,  and  it  is  this  pause  which  often  alarms  the 
patient.  After  the  long  pause  the  next  beat  is 
frequent!}^  big  and  powerful,  and  the  patient 
may  be  conscious  of  the  shock  due  to  this.  In 
nervous  people  this  big  beat  often  causes  much 
mental  anxiety. 

Another  curious  reflex  is  sometimes  met  with 
in  these  extra-systoles,  the  patient  giving  a  little 
gasp  or  cough  when  the  extra-systole  occurs. 

121.  Breathlessness. — Breathlessness  is  so  fre- 
quently associated  with  affections  of  the  heart  that 
its  occurrence  under  any  circumstance  necessitates 
a  consideration  of  the  heart's  condition.  It  is  so 
common  a  sign  of  exhaustion  of  the  reserve  force 
that  in  an  inquiry  into  a  patient's  cardiac  symptoms 
the  amount  of  exertion  that  can  be  undertaken 
before  breathlessness  occurs  should  be  carefully 
inquired  into.  In  many  cases  the  breathlessness 
may  occur  independently  of  any  bodily  exertion, 
coming  on  when  the  patient  is  in  bed,  and  persisting 
till  the  patient  has  to  sit  up  and  breathe  in  a 
laboured  fashion  (orthopnoea). 


228  Chapter  XX. 

The  mechanism  by  which  breathlessness  is 
brought  about  in  heart  affections  is  far  from 
clear,  and  so  many  factors  are  concerned  in  respira- 
tion that  any  endeavour  to  explain  its  cause  would 
lead  to  such  vague  and  indeterminate  speculation 
that,  in  the  present  state  of  our  knowledge,  little 
good  would  result.  The  great  point  is  to  observe 
the  fact,  to  exclude  other  possible  causes  of 
breathlessness  (as  affections  of  the  lungs,  mechanical 
obstructions  to  the  breathing,  anaemia,  and  other 
blood  affections),  and  then  from  a  study  of  the 
cardiac  conditions  to  determine  the  nature  of  the 
exhaustion  that  has  been  produced.  This  is  seldom 
a  matter  of  much  difficulty  when  a  sufficient  experi- 
ence of  the  various  forms  of  heart  disease  has  been 
acquired.  The  presence  of  a  demonstrable  lesion  in 
the  heart  may  be  a  guide,  as  shown  by  modification 
of  the  heart  sounds,  or  changes  in  the  size,  rate  and 
rhythm  of  the  heart.  In  the  absence  of  these  the 
age  of  the  patient  may  be  suggestive — if  old,, 
degenerative  changes  in  the  myocardium ;  if  young,, 
the  probability  of  some  general  infection,  as  tuber- 
culosis ;  if  middle-aged,  the  possibility  of  exhaus- 
tion of  the  reserve  force  from  over-work,  worry,  bad 
nourishment — in  fact,  the  consideration  of  the  fac- 
tors that  tend  to  exhaust  the  reserve  force  of  the 
heart,  breathlessness  being  often  the  first  sign  of 
such  exhaustion. 

Apart  from  breathlessness  brought  on  by 
exertion  there  are  som.e  definite  forms  of  breath- 
lessness which  are  recognised  as  especially  associated 
with  heart  affection.  The  best  known  of  these  is 
the  Cheyne-Stokes  respiration,  where  periods  of 
apnoea      alternate      with      periods      of      laboured 


Affections  of  the  Circulatory  System.         229 

breathing.  Another  characteristic  form  is  that  in 
which  patients  are  seized  in  the  night  with  attacks 
of  breathlessness,  and  have  to  sit  up  and  breathe 
in  laboured  fashion  for  periods  of  varying  duration, 
from  half-an-hour  to  several  hours.  This  form  of 
laboured  breathing  is  sometimes  spoken  of  as 
cardiac  asthma,  and  its  onset  is  often  mistaken  for 
the  more  common  form  of  asthma.  When  asthma  is 
found  to  occur  in  people  of  middle  or  advanced  age 
for  the  first  time,  the  possibility  of  its  cardiac  origin 
should  always  be  borne  in  mind. 

In  many  cases  the  patient  breathes  quietly 
though  hurriedly,  with  no  distress,  and  the  respira- 
tory condition  may,  in  consequence,  be  overlooked, 
though  the  rate  of  respiration  may  be  from  twenty 
to  thirty  tim.es  per  minute.  With  failing  hearts 
(as  in  typhoid  fever,  in  conditions  in  which  elderly 
people  are  forced  to  lie  in  bed,  or  in  valvular  disease) 
this  rate  tends  to  increase,  and  on  examination 
respiration  is  found  to  be  shallow  and  limited  to  the 
upper  portion  of  the  chest.  In  such  cases  there  will 
almost  always  be  found  evidence  of  stasis  or  oedema 
at  the  bases  of  the  lungs.  The  first  sign  of  this 
condition,  apart  from  the  increased  rapidity  of  the 
respiratory  movement,  is  the  detection  of  fine  crepi- 
tations on  deep  inspiration  heard  over  the  base  of  the 
lung,  on  that  side  towards  which  the  patient  habitu- 
ally lies.  My  usual  method  of  detecting  this  is  to 
ask  the  patient  on  which  side  he  has  lain,  and  then  to 
ask  him  to  sit  up  and  to  auscultate  the  base  of  the 
lung  on  the  side  on  which  he  has  lain.  This  is  the 
first  step  in  the  physical  examination  of  the  patient. 
If  done  at  a  later  stage  the  movements  may  have 
deepened  the  respiration,   so  that  the  crepitations 


230  Chapter  XX. 

have  disappeared.  One  usually  detects  the  fine 
crepitations  on  the  first  full  and  deep  inspiration. 
In  the  early  stages  of  pulmonary  stasis,  after  this 
thorough  ventilation  of  the  bases  of  the  lungs,  the 
crepitations  disappear.  If  measures  are  not  taken 
to  stop  this  tendency  to  oedema,  or  if  in  spite  of  all 
endeavours  the  oedema  increases,  the  crepitations 
become  more  numerous  and  persistent,  and  the 
lung  resonance  may  become  impaired.  In  fatal 
cases  the  bases  of  the  lungs  becom.e  dull,  there 
is  an  absence  of  the  respiratory  sounds,  and  post- 
mortem the  lungs  are  found  sodden  and  airless.  In 
suitable  cases  there  can  be  detected  coincident  with 
these  lung  symptom.s  evidences  of  the  dilatation  of 
the  right  heart,  as  epigastric  pulsation  due  to  the 
filling  and  emptying  of  the  dilated  right  ventricle. 

A  sense  of  suffocation  is  an  occasional  symptom 
in  heart  affections.  It  may  be  the  first  sign  of 
exhaustion  of  the  reserve  force,  coming  on  when  the 
patient  exerts  himself.  It  may  suddenly  seize  a 
patient  when  he  is  lying  in  bed.  Its  mechanism  is 
obscure.  The  sensation  is  usually  referred  to  the 
upper  part  of  the  chest  and  throat. 

122.  Viscero-sensory  and  Viscero  -  motor 
Reflexes. — Under  these  terms  I  include  such  sen- 
sory phenomena  as  pain  and  hyperalgesia  of  the  skin, 
muscles,  mammary  glands,  and  the  contraction  of  the 
muscles,  which  gives  rise  to  a  sensation  described 
"as  if  the  breast -bone  were  breaking."  After 
obtaining  a  full  account  of  the  patient's  sensations 
and  experiences,  if  careful  inquiry  be  made  in  regard 
to  a  number  of  symptoms,  as  pain,  constriction  of 
the  chest,  soreness  of  the  chest  or  arms,  frequent 
micturition,   increased  flow  of  saliva,   bad  dreams. 


Affections  of  the  Circulatory  System.         231 

there  will  be  found  a  number  of  phenomena  which 
the  patient  does  not  include  in  his  description, 
because  his  mind  is  occupied  with  the  sensations 
which  cause  him  suffering  and  discomfort.  The 
accurate  noting  of  these  less  obtrusive  phenomena 
will  often  throw  a  flood  of  light  on  many  an  obscure 
process  and  reveal  the  mechanism  by  which  the 
more  obtrusive  phenomena  are  produced. 

In  the  physical  examination  careful  testing  for 
hyperalgesia  should  first  be  made.  The  skin  of  the 
left  chest  should  be  lightly  pinched  and  compared 
with  that  of  the  right.  The  breasts  should  be 
lightly  compressed  and  the  resultant  sensations 
compared.  The  tenderness  to  pressure  of  the 
pectoralis  major  where  it  forms  the  anterior  wall  of 
the  left  axilla  should  be  tested.  In  the  same  way  the 
skin  of  the  neck  and  the  sterno-mastoid  should  be 
tested.  The  upper  edge  of  the  trapezius  muscle 
where  it  passes  from  the  scapula  to  the  neck  should 
be  lightly  compressed  along  its  whole  border,  and  it 
will  sometimes  happen  that  certain  areas  will  be 
found  very  tender.  These  are  places  where  a  small 
nerve  trunk-  is  pressed  upon.  Special  areas  of  ten- 
derness may  sometimes  be  found,  as  under  the  left 
breast,  and  over  the  second  and  third  ribs  in  the 
nipple  line.  In  one  patient,  where  this  latter  ten- 
derness was  very  marked,  I  found,  at  the  post-mortem 
examination,  on  dissection,  a  small  nerve  trunk  (the 
internal  anterior  thoracic  nerve). 

Angina  pectoris  affords  an  excellent  illustration 
of  the  application  of  the  principles  I  have  en- 
deavoured to  enunciate,  as  the  symptoms  can  be 
with  certainty  referred  to  the  organ  at  fault,  and 
because  the  complex  of  symptoms  that  are  included 


232  Chapter  XX. 

in  an  attack  of  angina  pectoris  are  capable  of  being 
analysed  with  great  precision.  This  is,  in  a  great 
measure,  due  to  the  peculiar  distribution  of  the  sen- 
sory nerves  in  whose  peripheral  distribution  the 
characteristic  phenomena  are  shown,  and  whose 
centres  in  the  spinal  cord  and  medulla  are  in  close 
relationship  to  the  centres  of  the  autonomic  nerves 
of  the  heart  (sympathetic  and  vagus).  The  cases  I 
cite  dem.onstrate  that  the  term  "  angina  pectoris  " 
includes  a  number  of  reflexes,  and  I  give  in  detail 
the  more  conspicuous  of  these,  namely,  sensory 
reflexes,  where  the  pain  and  hyperalgesia  affect  the 
chest,  arm,  head,  and  neck  ;  motor  reflexes,  resulting 
in  spasm  of  the  intercostal  muscles ;  secretory 
reflexes,  shown  by  profuse  secretion  of  saliva  and 
urine.  Some  cases  show  other  reflexes,  as  the 
respiratory,  but  the  discussion  of  these  would  lead 
me  beyond  the  object  I  had  in  writing  this  book. 

Notwithstanding  the  numerous  papers  devoted 
to  the  consideration  of  angina  pectoris,  practically 
none  have  dealt  adequately  with  the  analysis  of  the 
symptoms  present  during  an  attack.  Angina  pec- 
toris is  often  surrounded  by  such  tragic  circum- 
stances that  it  forms  a  suitable  theme  for  disquisition, 
and  on  that  account  we  too  often  get  the  lurid 
description  of  an  impressionist  artist  instead  of 
the  plain,  matter-of-fact  description  of  an  accurate 
observer.  A  careful  sifting  of  all  the  details  brings 
out  the  fact  that  the  essential  principles  underlying 
the  pains  associated  with  affections  of  the  heart 
differ  in  no  way  from  those  of  any  other  hollow 
muscular  organ.  So  terrifying  is  the  attack  to  the 
patient  that  his  perceptions  of  the  details  of  his 
suffering  are  generally  confused,   so  that  often  no 


Affections  of  the  Circulatory  System.         233 

•clear  account  can  be  obtained  from  his  description  ; 
but  if  he  is  intelhgent  and  is  asked  to  note  particu- 
lars in  subsequent  attacks,  he  may  be  able  to  throw 
a  very  valuable  light  on  the  onset  and  character 
of  the  sensations  he  experiences.  The  observations 
made  by  the  physician  of  patients  during  an  attack 
also  afford  great  help  in  this  respect. 

123.  The  Viscero-sensory  Reflexes  in  Dilata- 
tion of  the  Heart  and  Liver. — Before  dealing  with 
the  more  characteristic  attacks  of  heart  pain 
which  go  by  the  name  of  angina  pectoris,  I  wish 
first  to  draw  attention  to  the  very  distinct  sensory 
evidences  that  arise  from  the  dilatation  of  the 
heart.  These  sensory  symptoms  are  practically 
identical  with  those  that  arise  in  cases  of  distension 
of  any  other  viscus,  as  the  stomach,  bladder  or  liver. 
To  illustrate  this  I  select  cases  where  the  dilatation 
of  the  heart  occurs  rapidly,  and  is  followed  by  a 
rapid  distension  of  the  liver,  such  as  we  find  in 
certain  forms  of  paroxysmal  tachycardia.  In  cer- 
tain of  these  cases  the  rhythm  of  the  heart  starts 
suddenly  at  some  abnormal  place  in  the  auricle  or 
ventricle,  or  at  the  fibres  joining  auricle  and  ven- 
tricle. The  heart  at  once  beats  with  great  rapidity, 
but  fails  to  maintain  the  circulation,  and  in  conse- 
quence we  have  very  rapidly  developed  great  dila- 
tation of  the  heart,  fullness  of  the  veins,  enlargement 
of  the  liver,  and  dropsy.  I  have  seen  a  number  of 
these  cases,  and  in  two  particularly  T  have  observed 
some  fifteen  to  twenty  attacks,  of  which  the  following 
is  a  typical  description. 

The  patient  may  be  in  good  health  and  no 
abnormality  be  detected  save,  in  some  cases,  the 
•occurrence     of    an    extra-svstole.        Suddonlv    the 


234 


Chapter  XX, 


Fig.   16. 

The  areas  shaded  in  the  neck,  chest  and  upper  part  of  the  abdomert 
represent  the  distribution  of  cutaneous  hyperalgesia  in  a  patient  suffering 
from  acute  dilatation  of  the  heart  and  liver. 


heart's  rate  becomes  greatly  accelerated,  to  150  beats 
and  more  per  minute.  In  a  few  hours  the  patient's 
face  becomes  duskj^  the  lips  swollen  and  livid,  and 
there  appears  great  shortness  of  breath  on  exertion, 
marked  increase  in  the  size  of  the  heart,  distension 
and  pulsation  of  the  veins  of  the  neck,  and  enlarge- 
ment and  pulsation  of  the  liver.  The  j  ugular  and  liver 
pulsation  are  of  the  ventricular  type.  Pain  and 
oppression  may  be  felt  over  the  chest.  The  skin  and 
deeper  tissues  of  the  left  chest  become  extremely 
tender  on  pressure  in  the  area  shaded  in  Fig.  16.     If 


Affections  of  the  Circulatory  System.         235 

the  left  pectoralis  major  muscle  be  grasped  where  it 
forms  the  axillary  fold  it  will  be  found  extremely 
tender.  The  skin  of  the  left  side  of  the  neck  may 
also  be  tender,  and  if  the  left  sterno-mastoid  muscle 
and  the  left  trapezius  m.uscle,  above  the  middle  of 
the  scapula,  are  lightly  grasped  they  may  be  found 
exquisitely  sensitive.  The  skin  and  muscles  over  the 
liver  will  also  be  found  extrem.ely  sensitive  to  pres- 
sure, and  the  parts  hyperalgesic  extend  over  a  much 
larger  area  than  the  enlarged  liver.  If  the  heart's 
rate  revert  to  the  normal  the  patient  at  once  experi- 
ences great  relief,  and  in  a  few  hours  all  signs  of 
the  circulatory  disturbances  disappear.  The  hyper- 
algesia may  last  with  diminishing  severity  for  a  few 
days.  The  tenderness  of  the  skin  and  muscles  in 
the  regions  described  above  may  be  found  in  patients 
during  the  early  stages  of  dilatation  of  the  heart 
from  any  cause,  and  is  very  common  in  heart  failure 
secondary  to  mitral  disease.  Tn  some  cases  one  can 
tell  when  improvement  is  taking  place  by  noting  the 
diminution  of  this  tenderness. 

There  can  be  little  doubt  as  to  the  mechanism 
by  which  the-  hyperalgesia  of  the  tissues  in  the 
three  re^jions  is  brouglit  about.  The  relation  of  the 
dilatation  of  the  heart  and  liver  with  these  sensory 
phenomena  is  undoubtedly  that  of  cause  and  effect. 
The  tenderness  to  pressure  of  the  tissues  in  the 
left  chest  is  due  to  stimulation  of  the  afferent 
sympathetic  nerves  by  the  dilated  heart.  These 
nerves  stimulate  the  sensory  centres  of  the  third  and 
fourth  thoracic  nerves  in  the  spinal  cord,  so  that  a 
stimulus  reaching  them  from  their  peripheral  dis- 
tribution gives  rise  to  a  pninful  impression.  The 
tenderness  of  the  left  sterno-mastoid  and  trapezius 


236  Chapter  XX. 

muscle,  and  of  the  skin  of  the  neck,  is  due  to  the 
afferent  fibres  of  the  "  bulbar  autonomic  "  system — 
that  is  the  vagus,  conveying  a  stimulus  to  the  sensory 
roots  of  the  second  and  third  cervical  nerves.  The 
hyperalgesia  of  the  tissues  covering  the  liver  is 
due  to  stimulation  of  the  sensory  centres  in  the 
spinal  cord  by  the  afferent  sympathetic  fibres  from 
the  engorged  liver. 

124.  The  Pain  of  Angina  Pectoris  is  a 
Viscero-sensory  Reflex. — The  usual  description  given 
of  the  pain  in  angina  pectoris  is  that  it  is  felt  in 
the  heart  and  shoots  into  the  arm,  or  that  there 
are  two  pains,  a  local  pain  in  the  heart  and  a  referred 
pain  in  the  arm.  If,  however,  a  careful  analysis 
be  made  of  all  the  symptoms  present,  facts  will 
be  found  that  practically  demonstrate  that  in 
angina  pectoris  there  is  but  one  kind  of  pain,  and 
that  its  production  is  in  accordance  with  the  law  I 
have  attempted  to  establish,  namely,  that  it  is  a 
viscero-sensory  reflex.  One  is  not  able  in  every  case 
to  demonstrate  the  proofs  of  this  hypothesis,  but 
facts  derived  from  suitable  cases  afford  legitimate 
conclusions  applicable  to  all  cases.  Shortly,  these 
facts  are,  that  the  pain  in  the  very  gravest  cases 
may  be  felt  in  regions  distant  from  the  heart ;  that 
this  pain  is  identical  in  character  with  that  felt  over 
the  heart ;  that  the  pain  may  originally  start  in  parts 
distant  from  the  heart,  and  gradually  approach  and 
settle  over  the  heart ;  and,  lastly,  that  the  tissues 
of  the  external  body  wall,  in  the  exact  region  in 
which  the  pain  was  felt,  may  be  found  extremely 
hyperalgesic  after  the  pain  has  passed  away.  From 
this  last  fact  it  is  inferred  that,  inasmuch  as  the  seat 
of  pain  corresponds  to  the  region  of  hyperalgesia. 


Affections  of  the  Circulatory  System.        237 

therefore  the  pain  was  due  to  stimulation  of  the 
hyperalgesia  nerves.  To  assume  otherwise  would  be 
to  ignore  a  principle  that  explains  satisfactorily  the 
sensation  of  pain  wherever  arising. 

The  following  observations  illustrate  this  point. 
They  are  examples  chosen  from  a  large  number  of 
cases  that  demonstrate  the  same  feature.  For  the 
sake  of  brevity  only  those  points  bearing  upon  this 
argument  are  referred  to. 

Female,  aged  30,  suffering  from  stenosis  of  the 
aortic,  mitral,  and  tricuspid  valves,  was  seized 
with  a  violent  pain  referred  to  the  outer  part  of  the 
left  side  of  the  chest  wall.  The  pain  passed  off,  but  a 
sense  of  soreness  and  smarting  remained  over  the 
part  in  which  the  pain  was  felt.  On  examining  her 
I  found  a  portion  of  the  skin  of  the  chest  extremely 
tender  to  touch,  corresponding  to  the  area  shaded  in 
Fig.  17. 

A  few  days  later  she  began  to  suffer  from 
attacks  of  pain  in  the  left  breast  and  down  the 
inside  of  the  left  arm,  and  on  examination  I  found 
that  the  hyperalgesia  had  extended  and  occupied  an 
area  similar  to  that  shaded  in  Fig.  18. 

These  attacks  of  pain  became  so  severe  on  the 
slightest  exertion  that  she  was  obliged  to  keep  to 
her  bed.  She  partially  recovered  from  these  attacks, 
but  they  recurred  with  increased  severity.  When 
suffering  the  most  severe  attacks  the  hyperalgesia 
embraced  nearly  the  whole  of  the  left  chest  and 
inside  of  the  left  arm,  and  also  a  portion  of  the  right 
chest.  The  left  sterno-mastoid  muscle  and  trapezius 
also  became  very  tender,  and  the  patient  would 
sometimes  complain  of  pain  on  the  inner  surface  of 
the  right  arm,  at  the  elbow,  where  also  I  found  a 


238 


Chapter  XX, 


Fig.   17. 

The  shaded  area  shows  the  distribu- 
tion of  the  cutaneous  hyperalgesia  after 
the  first  attack  of  angina  pectoris  (com- 
pare with  fig.  18). 


Ftg.    18. 

After  repeated  attacks  of  angina 
pectoris  the  pain  and  hyperalgesia  ex- 
tended to  the  regions  shaded  here. 
Note  the  areas  in  the  neck  and  inner  side 
of  right  elbow  (compare  with  figs.  6  and  7). 


Affections  of  the  Circulatory  System.         239 

^atch  of  cutaneous  hyperalgesia.  Two  j^ears  and  a 
half  after  the  first  attack  of  pain  she  was  recovering 
from  a  series  of  violent  attacks,  when,  on  getting  out 
of  bed,  she  fell  forward  and  died  immediately. 

The  fact  that  in  this  case  the  attacks  of  pain 
were  followed  by  a  h^^peralgesia  of  the  skin  in  the 
region  where  the  pain  was  felt,  and  the  further  fact 
iihat  the  pain  started  at  a  distance  from  the  cardiac 
region,  and  was  often  felt  most  severely  at  a  distance 
from  the  heart,  proves  that  the  cardiac  pain  in  this 
case  was  a  viscero-sensory  reflex,  and  that  the  pain 
felt  over  the  precordia  was  presumably  of  the  same 
nature. 

Female,  aged  56,  with  high  blood  pressure, 
suffers  from  pain  in  the  foot  (gout),  and  has  had 
several  severe  attacks  of  true  angina  pectoris,  in 
which  the  pain  is  referred  over  the  left  chest  and 
through  to  the  shoulder.  After  the  attack  she 
passes  a  large  quantity  of  clear  urine,  and  the 
skin  and  deeper  tissues  of  the  left  breast  and  the 
left  sterno-mastoid  and  trapezius  muscles  become 
very  tender  on  pressure.  In  one  attack  the  pain 
was  felt  in  a  limited  area  over  the  second  left  inter- 
space, and  next  morning  I  found  the  skin  and 
deeper  tissues  at  this  place  extremely  tender  to  the 
slightest  pressure. 

In  this  instance,  also,  the  hyperalgesia  of  the 
skin  corresponded  to  the  region  where  pain  was 
felt,  and  is  presumptive  evidence  in  favour  of  the 
view  that  the  pain  as  well  as  the  hyperalgesia  is  the 
result  of  the  viscero-sensory  reflex. 

Male,  aged  42,  consulted  me  on  October  18th, 
1 905,  complaining  of  pain  in  the  left  little  finger  and 
ulnar  border  of  the  left  ami  and  forearm,  coming 


240  Chapter  XX. 

on  when  he  exerted  himself  at  his  work  and  on  going- 
up  hill.     For  some  months  he  suffered  from  a  dull 
aching  pain  at  the  back  over  his  shoulder  blades. 
I  found  dilatation  of  the  aorta,  slight  incompetence 
of  the  aortic  valves,  and  slight  enlargement  of  the 
heart    (verified    at    the    subsequent    post-mortem 
examination).    The  blood  pressure  was  150  mm.  Hg. 
During  the  following  weeks  the  pain  in  the  left  arm 
increased  in   severity,    gradually   extended   up   the 
arm  till  it  was  felt  in  the  axilla,  and  finally  invaded 
the  left  chest.     At  first  the  pain  was  wont  to  start 
at  the  little  finger  and  to  pass  rapidly  up  the  arm, 
but  latterly  it  seized  him  with  such  severity  and 
suddenness  that  he  could  not  tell  where  it  began. 
It  usually  held  him  with  the  greatest  severity  either 
over  the  heart  or  in  the  inner  surface  of  the  left  arm 
immediately   above  the  internal   condyle.      I   par- 
ticularly asked  him  to  note  in  his  frequent  attacks- 
if  there  was  a  difference  between  the  arm  pain  and 
the  chest  pain,  and  his  reply  was  that  there  was  no- 
difference  in  the  character  of  the  pain,  but,  if  any- 
thing, the  arm  pain  was  the  worse.    Sometimes  the 
pain  was  very  severe  up  the  left  side  of  the  neck  and 
behind  the  left  ear.     Under  treatment  he  seemed  to 
make  considerable  improvement.     During  January, 
1906,  these  attacks  recurred.     During  some  of  them 
the  pain  was  so  agonising  that  he  felt  he  was  djdng, 
and  wished  to  die.     The  pain  was  equally  severe  in 
chest    and    arm,    and    saliva    sometimes    dribbled 
from    his    mouth.       On    February    12th    the    least 
exertion  was  sufficient  to  induce  a  severe  attack  of 
pain ;    from    three    p.m.    to    seven    p.m.    he    was- 
scarcely    free    from    pain,    and    ultimately    became 
unconscious.     When  I  saw  him  next  day  he  was. 


Affections  of  the  Cnculatory  System.         241 

having  another  series  of  attacks.  He  was  keeping 
his  left  arm  very  still,  and  helping  himself  to  food 
entirely  with  his  right  hand.  He  told  me  he  dare  not 
move  his  left  arm,  as  even  the  act  of  lifting  the  left 
hand  to  his  month  was  sufficient  to  induce  an 
attack.  His  pulse  was  extremeh'^  soft  and  weak. 
His  blood  pressure  had  fallen  to  95  mm.  Hg. 
During  the  following  night  he  had  another  series  of 
attacks,  became  unconscious  and  expired. 

I  omit  man}^  details  in  this  case  on  purpose  to 
emphasise  the  regions  in  which  the  pain  was  felt  in 
a  case  of  the  most  severe  form  of  angina  pectoris. 
It  seems  to  me  that  no  other  explanation  save 
that  of  the  viscero-sensory  reflex  can  satisfactority 
account  for  the  pains  in  this  case,  and  to  attempt 
to  distinguish  the  chest  pain  as  a  heart  pain  and 
the  pain  in  the  arm  as  a  referred  pain  would  be 
arbitrary,  illogical,  and  opposed  to  the  evidence. 
The  radiation  of  the  pain  from  the  hand  to  the 
chest  was  practically  of  the  same  nature  as  the 
more  common  radiation  of  the  pain  from  the  chest 
to  the  hand.  The  pain  in  the  neck  and  behind  the 
ear,  on  the  same  hypothesis,  would  be  induced  b}^ 
the  stimulus  passing  from  the  heart  by  the  vagus, 
a  view  that  would  also  explain  the  increased  flow  of 
saliva  during  some  of  the  attacks,  points  to  which 
I  shall  afterwards  revert. 

It  is  interesting  to  note  here  that  the  movement 
of  the  left  arm  would  induce  an  attack  of  angina 
pectoris.  I  have  already  pointed  out  (page  89) 
that  a  stimulus  from  any  source  reaching  an  irritable 
focus  in  the  cord  will  cause  the  characteristic  pain 
to  arise.  In  the  next  observation  the  stimulus 
reached  the  cord  from  the  skin  of  the  chest. 


242  Cha'pter  XX. 

The  two  following  observations  of  attacks  of 
angina  pectoris  which  I  witnessed  illustrate  true 
heart  pain  of  the  most  severe  tj^pe  at  places  remote 
from  the  heart. 

Male,  aged  14,  suffering  from  adhesive  medias- 
tinitis,  with  enormous  enlargement  of  the  heart. 
The  patient  lay  propped  up  in  bed.  As  I  was  gently 
testing  the  sensibility  of  the  skin  outside  and  under 
the  left  nipple  the  patient  was  suddenly  attacked 
with  severe  pain.  He  gave  a  great  sob,  and  leant 
forward  with  his  left  upper  arm  across  his  chest, 
and  his  right  hand  pressing  it  gently.  He  rocked 
backwards  and  forwards  with  deep  sobs,  while  tears 
streamed  down  his  cheeks.  His  pulse  became  very 
soft  and  his  face  pale,  with  beads  of  perspiration 
on  his  forehead.  In  a  few  minutes  the  pain  sub- 
sided and  he  lay  back  exhausted.  Afterwards  he 
said  that,  on  my  touching  a  certain  spot,  a  pain  shot 
from  his  chest  to  his  arm,  and  during  the  whole 
time  the  awful  pain  remained  in  his  arm,  and  he  put 
his  hand  over  the  fleshy  part  of  the  upper  arm.  His 
doctor  told  me  he  had  given  up  examining  him  by 
auscultation,  because  on  a  few  occasions,  on  applying 
the  stethoscope,  attacks  similar  to  those  I  had  wit- 
nessed were  induced. 

Female,  aged  60,  complained  of  pain  of  agon- 
ising severity  limited  to  the  ulnar  border  of  the 
left  forearm.  Coming  to  see  me  one  day  she  hurried 
to  catch  the  train,  and  when  she  reached  my  con- 
sulting room  she  sat  down.  In  a  few  minutes  the 
pain  seized  her,  and  she  took  up  her  left  arm  and 
nursed  it  across  her  breast  with  evidences  of 
great  suffering.  The  pain  subsided  in  a  few  moments, 
and  she  said  she  felt  as  if  she  would  have  died. 


Affections  of  the  Circulatory  System.         243 

The  pain  was  felt  nowhere  but  in  the  left  forearm. 
Three  months  afterwards  the  patient  died  from 
heart  failure.  At  the  post-mortem  examination 
there  was  found  marked  atheroma,  calcification  of 
the  coronary  arteries  and  extensive  chronic  fibrous 
myocarditis. 

In  this  last  case  the  pain  was  doubtless  limited 
to  the  highest  sensory  nerve  centre  (first  thoracic), 
whose  fibres  are  associated  with  the  sympathetic 
supply  of  the  heart. 

125.  Evidences  of  the  Viscero-motor  Reflex. — 
So  far  I  have  dealt  with  the  viscero-sensor}^  reflex, 
and  evidence  no  less  striking  can  be  found  of  the 
viscero-motor  reflex  among  the  group  of  s^^mp- 
toms  included  in  the  term  "  angina  pectoris."  Some 
would  limit  the  term  "  angina  pectoris  "  to  that  class 
of  cases  where,  in  addition  to  the  pain,  there  is  a 
sense  of  constriction  in  the  chest,  amounting  at  times 
to  a  sensation  as  if  the  chest  were  gripped  in  a 
vice,  or  as  if  the  breast-bone  would  break.  I  am 
convinced  that  these  sensations  arise  from  spasm 
of  the  intercostal  muscles,  and  correspond  to  the 
hard  contraction  of  the  flat  abdominal  muscles  in 
affections  of  the  abdominal  viscera.  If  one  watches 
a  case  of  what  is  called  "  muscular  rheumatism  " 
where  the  intercostal  muscles  are  affected,  and 
where  these  muscles  are  stimulated  by  the  slightest 
movement  to  violent  cramp-like  contractions,  one 
cannot  but  be  struck  by  the  resemblance  to  the 
description  given  of  the  "  gripping "  sensation 
experienced  by  patients  suffering  from  certain 
affections  of  the  heart.  I  have  watched  the  attacks 
in  such  cases  and  could  find  no  difference  between 
them  and  those  where  the  sense  of  constriction  was 


244  Chapter  XX. 

the  chief  symptom  in  heart  disease.  The 
viscero-motor  reflex  may  be  present  alone,  or,  as  is 
more  commonly  the  case,  it  may  be  associated  with 
pain.  The  pm^ely  viscero-motor  reflex  is  seen  best 
in  the  elderly,  where  it  may  be  considered  as  a 
symptom  of  one  form  of  the  terminal  affections  of 
the  heart  due  to  arterio-sclerosis  or  old  age.  I  have 
fomid  it  a  precursor  of  steadily  advancing  cardiac 
weakness,  and  although  for  a  time  considerable 
relief  may  be  afforded,  the  changes  in  the  heart  are  so 
advanced  that,  in  the  nature  of  things,  only  one  end 
can  be  looked  for.  The  three  following  observations 
illustrate  these  views. 

Male,  aged  82,  with  large  tortuous  arteries, 
was  seized  while  walking  with  a  sense  of  constriction 
across  the  chest  that  compelled  him  to  stand  still. 
These  attacks  became  so  frequent  and  so  severe 
that  he  could  scarcely  walk  fifty  yards  before  he  had 
to  stop  and  lean  against  the  wall.  He  described 
the  sensation  as  one  not  of  pain,  but  as  if  somebody 
gripped  the  upper  part  of  the  chest  with  a  strong 
hand.  With  rest  and  suitable  treatment  these 
attacks  gradually  disappeared.  Three  months  later 
the  heart  suddenly  became  irregular  (auricular 
fibrillation),  dropsy  set  in,  and  he  died  seven  weeks 
later  from  heart  failure. 

Male,  aged  56,  was  seized  with  a  spasm  which 
held  his  chest  as  in  a  vice  when  he  walked  up  a  hill. 
There  was  no  pain  but  the  sense  of  constriction  and  a 
sense  of  suffocation  produced  such  discomfort  that  he 
was  forced  to  stand  still.  Within  a  few  minutes  the 
chest  would  feel  free,  but  the  sensation  would  at  once 
recur  if  he  attempted  further  effort  of  the  same 
kind.     Thus,  in  going  to  business,  he  had  to  go  up 


Affections  of  the  Circulatory  System.         245 

a  steep  hill,  but  frequenth^  found  it  impossible  to  do 
so,  and  then  had  to  go  downhill  and  reach  his  des- 
tination by  another  and  less  steep  road. 

Female,  aged  78.  Two  years  before  her  death 
she  experienced  attacks  of  breathlessness  with  a 
sensation  of  constriction  across  the  chest.  This 
feeling  of  tightness  was  so  readily  set  up  that  she 
was  obliged  to  stay  in  bed.  The  attacks  dis- 
appeared, but  recurred  again  shortly  before  her 
death.  These  latter  attacks  were  accompanied  b}" 
slight  precordial  pain.  She  became  gradually  weaker 
and  died.  At  the  post-mortem  examination  the 
coronary  arteries  were  found  markedl}^  thickened, 
with  calcareous  patches  in  their  walls. 

The  following  experience  illustrates  the  fact 
that  the  viscero-motor  reflex  is  a  symptom  distinct 
from  the  pain. 

Male,  aged  48,  consulted  me  on  November  25th, 
1905,  for  a  pain  he  felt  across  the  middle  of  his 
chest.  He  had  felt  a  slight  pain  here  for  some 
months  on  walking  up  a  hill.  He  was  a  master-builder, 
and  on  this  day,  while  watching  his  men  at  work, 
feeling  cold,  he  began  to  help  them  to  dig  up  som.e 
earth,  to  warm  himself.  He  did  this  for  a  quarter  of 
an  hour  with  a  good  deal  of  energy.  He  then 
examined  a  few  partially  built  houses,  running  up 
and  down  a  great  many  steps.  On  his  way  home  he 
became  conscious  of  pain  in  his  chest,  and  as  it  con- 
tinued to  increase  in  severity  he  called  on  me.  I 
examined  him  carefully,  and  found  a  slight  dilata- 
tion of  the  heart  with  an  impure  first  sound.  The 
blood  pressure  was  1.30  mm.  Hg.  On  liis  way  home 
tlie  pain  increased  in  severity,  and  after  he  reached 
liome  it  became  very  violent.     A  colleague  saw  him 


246  Chapter  XX. 

and  prescribed  opium,  which  reheved  him.  When  1 
saw  him  next  morning  he  gave  a  graphic  account  of 
his  sufferings.  He  said  :  "In  the  tram  coming  home 
the  pain  got  worse,  and  after  getting  home  it  became 
so  severe  that  I  felt  I  was  going  to  die.  The  pain 
spread  from,  my  chest  down  my  left  arm  to  my  little 
finger.  You  asked  me,  when  I  saw  you  yesterday,  if 
I  felt  any  gripping  sensation,  and  I  did  not  know 
what  you  meant ;  but,  by  George  !  I  know  now.  When 
the  pain  was  at  its  worst,  I  felt  my  chest  suddenly 
seized  as  in  a  vice,  and  I  rolled  on  the  floor  in  agon}^ 
The  pain  and  the  gripping  eased  off  for  a  time  and 
then  came  on  again.  This  continued  till  I  got  the 
opium.  This  morning  I  awoke  all  right,  but  at  10.30 
that  gripping  sensation  came  on  and  held  me  tight 
for  ten  minutes.  I  dare  not  move  for  fear 
the  awful  pain  should  come  on,  and  I  felt 
every  moment  it  was  about  to  come,  and  I 
was  in  such  terror  of  it  that  the  sweat  poured 
off  me." 

With  rest  and  treatment  these  attacks  grew  less, 
till  he  only  felt  a  slight  pain  when  he  over-exerted 
himself. 

So  far  the  symptoms  I  have  dealt  with  have 
been  mainly  concerned  with  the  reflexes  connected 
with  the  sympathetic  nerve  supply.  Equally 
instructive  symptom.s,  though  less  frequent,  can  be 
shown  to  arise  from  stimulation  of  the  vagus.  At 
its  centre  in  the  medulla  this  nerve  is  in  near  rela- 
tionship to  the  upper  cervical  nerves,  and,  it  would 
seem,  more  particularly  the  sensory  nerves  supplying 
the  sterno-mastoid  and  trapezius  muscles.  Not  only 
may  these  muscles  become  extreme^  tender  in  various 
heart  affections,  but  the  pain  from  heart  affections 


Affections  of  the  Circulatory  System.         247 

ma}'  be  felt  in  the  region  of  distribution  of  the  cer- 
vical nerves  as  alreach'  noted.  The  following  obser- 
vations also  show  the  same  thing. 

]Male,  aged  62,  complained  of  great  pain  striking 
into  his  chest  and  behind  his  ears  when .  walking. 
Thus,  in  going  to  his  work,  he  allowed  seven  or 
eight  minutes  to  walk  to  the  station,  but  now  it  took 
him  over  half  an  hour,  as  he  had  to  stop  on  account 
of  the  pain  ever}'  fifty  yards.  After  accurately 
noting  the  pain  he  described  it  as  arising  in  the  left 
breast,  extending  across  to  the  right  breast,  seizing 
him  in  the  neck,  and  extending  up  behind  the  ears, 
where  it  held  him  with  great  severity.  In  showing 
me  the  situation,  he  laid  the  fingers  of  both  hands 
over  the  insertion  of  the  sterno-mastoid  muscle  into 
the  mastoid  process.  On  one  occasion  the  pain  ex- 
tended from  the  breasts  to  the  armpits,  and  down 
the  side  of  each  arm  to  the  elbow. 

This  patient  dropped  dead  while  at  his 
work,  and  on  post-mortem  examination  I  found 
extreme  calcareous  degeneration  of  the  coronary 
arteries. 

126.  Organic  Reflexes  occurring  during  an 
Attack  of  Angina  Pectoris. — Other  very  striking 
plienomena  are  sometimes  met  with  during  an 
attack  of  angina  pectoris.  During  or  after  an 
attack  an  abundant  flow  of  saliva  and  the  secretion 
of  large  quantities  of  pale  urine  may  occur  ;  both 
symptoms  I  suggest  are  due  to  reflex  stimulation  of 
nuclei  in  the  floor  of  the  fourth  ventricle.  Possibly 
the  polyuria  may  be  of  the  same  character  as  that 
in  diabetes  insipidus,  which,  as  is  well  known,  may 
be  induced  in  animals  by  puncture  of  the  floor  of 
the  fourth  ventricle. 


248  Chapter  XX. 

Male,  aged  58,  of  gouty  diathesis,  complained 
of  pain,  induced  b}^  the  slightest  exertion,  which 
arose  in  the  left  breast,  passed  up  the  armpit,  and 
extended  down  the  inner  surface  of  the  left  arm  to 
the  little  finger.  During  an  attack  an  abundant  flow 
of  saliva  took  place  into  the  left  side  of  the  mouth. 
These  attacks  became  so  frequent  that  he  could  only 
walk  a  ver}^  short  distance  without  inducing  an 
attack.  He  died  while  sitting  at  his  desk,  and  at 
the  post-mortem  examination  I  found  that  the  heart 
had  ruptured,  and  the  coronary  artery  was  very 
atheromatous.  Where  the  rupture  had  taken  place 
the  myocardium  had  nearly  disappeared. 

Male,  aged  46,  whose  work  entailed  periods 
of  great  muscular  exertion,  complained  of  pain 
striking  into  the  chest  when  walking  up  a  hill. 
If  he  stopped  as  soon  as  he  felt  the  pain  coming  on, 
it  passed  off,  but  if  he  persisted  the  pain  increased 
to  an  agonising  severity  and  radiated  into  both 
arms,  but  worse  into  the  left,  as  far  down  as  the 
little  finger.  At  the  same  time  the  chest  was  gripped, 
so  that  he  was  forced  to  straighten  himself  and  to 
breathe  deeply,  and  at  the  same  time  his  mouth  filled 
with  saliva,  and  an  aching  pain  was  felt  in  the 
throat.  A  few  minutes  after  each  attack  he  had  to 
pass  urine,  which  was  always  abundant  and  ver}^ 
clear.  These  details  I  had  from  him  after  he  had 
carefully  noted  a  number  of  attacks. 

127.  Summation  of  Stimuli  as  a  Cause  of 
Angina  Pectoris. — The  fundamental  functions  of 
the  heart  muscle  correspond  to  those  of  other  in- 
voluntary muscles  that  form  the  walls  of  hollow 
organs  ;  these  functions  being  modified  to  suit  its 
special  work.     Like  the  other  viscera  the  heart  is 


Affections  of  the  Circulatory  System.         249 

insensitive  when  stimulated  in  a  manner  that  pro- 
vokes pain  when  applied  to  the  tissues  of  the  exter- 
nal body  wall.  I  have  pointed  out  that  a  long  strong 
contraction  of  a  hollow  organ  can  produce  pain,  and 
that  this  is  undoubtedly  the  cause  of  the  severe  pain 
associated  with  renal  calculus,  gall-stones,  spasm  of 
the  bowel,  and  uterine  contractions.  Can  the  heart 
^ive  rise  to  pain  in  a  similar  manner  ?  On  account 
of  the  modification  of  its  functions,  the  heart  cannot 
pass  into  a  prolonged  state  of  contraction.  Imme- 
diately it  contracts,  the  function  of  contractility  is 
abolished  and  the  muscle  passes  at  once  into  a  state 
of  relaxation,  and  for  this  reason  the  pain  cannot  be 
produced  by  a  "  spasm  of  the  heart."  But  I  suggest 
that  the  heart  muscle  may  produce  pain  when  it  is 
confronted  with  work  greater  than  it  can  readily 
overcome,  a  condition  which  produces  strong  peri- 
stalsis and  pain  in  other  hollow  viscera.  But  the  pain 
in  the  heart  arises  by  a  slightl}^  different  mechanism. 
A  skeletal  muscle  will  contract  in  obedience  to 
stimulation  of  a  sensory  nerve  going  to  the  spinal 
centre  of  its  nerve,  if  a  stimulus  of  sufficient  strength 
be  applied.  If  the  stimulus  be  too  weak,  no  contrac- 
tion follows,  but  if  this  weak  stimulus  be  frequently 
and  rapidly  repeated,  then  the  muscle  contracts  in 
accordance  with  the  law  of  the  summation  of  stimuli. 
I  suggest  that  the  heart  muscle  induces  pain  on  the 
principle  of  summation  of  stimuli.  If  we  minutely 
study  our  cases  we  shall  find  that  the  pain  rarely 
arises  at  the  first  exposure  of  the  heart  to  the  effort 
that  induces  the  pain.  Sometimes  effort  has  been 
undertaken  a  few  niinutes  before  the  pain  comes  on, 
and  in  certain  cases  it  may  not  come  on  for  hours 
after  the  casual  exertion  has  ceased. 


250  Chapter  XX. 

From  such  observations  we  can  infer  that  th& 
heart  muscle  was  exhausted  by  the  exertion,  and  sa 
great  was  the  exhaustion  of  the  reserve  force  that 
it  was  unable  to  regain  its  reserve  on  cessation 
of  effort ;  thus  the  exhaustion  persisted  till  it 
culminated  in  an  attack  of  angina  pectoris. 


(     251     ) 


Chapter    XXL 

ESTIMATION    OF    THE    VALUE    OF 
SYMPTOMS. 

128.  The  Relation  of  the  Symptoms  to  the  General 

State. 

129.  Remote  Effects  of  the  Lesion. 

130.  Relation  of  Symptoms  arising  from  different 

Causes. 

131.  The  Bearing  of  Symptoms  on  Prognosis. 

132.  The  Bearing  of  Symptoms  on  Treatment. 

In  this  chapter  I  endeavour  to  sum  up  the 
general  principles  which  have  been  applied  in  more 
detail  in  the  earlier  chapters.  That  the  interpre- 
tation of  symptoms  should  be  imperfect  can  readily 
be  recognised,  for  not  only  is  the  subject  too  vast 
to  be  dealt  with  in  a  few  pages,  but  the  knowledge 
to  deal  with  it  efficientl}^  is  lacking.  I  confine  myself, 
therefore,  to  a  few  general  principles  that  have 
been  of  service  to  me  in  my  endeavours  to  estimate 
the  value  of  symptoms  in  individual  cases. 

128.  The  Relation  of  the  Symptoms  to  the 
General  State. — Before  a  hnal  opinion  is  form.ed 
of  the  value  of  any  symptom,  the  physician  must 
consider  the  patient  as  a  whole,  and  the  relation 
of  any  abnormal  sign  to  the  general  health.  The 
patient's  complaint  may  be  of  a  trivial  nature,  and 
the  examination  of  the  different  organs  may  reveal 


252  Chapter  XXI. 

no  abnormality ;  nevertheless  the  contemplation 
of  the  patient's  whole  economy  may  help  one  not 
to  dismiss  the  symptoms  too  hastily  because  of  their 
seeming  triviality.  Malignant  disease  of  the  stomach 
may  cause  the  symptoms  of  a  simple  indigestion,  but 
a  slight  loss  in  weight  and  a  slight  change  in  the 
patient's  colour  may  ultim.ately  be  found  to  indicate 
the  grave  nature  of  the  illness.  The  description  of 
the  patient's  complaint  may  be  given  in  such  term.s 
that  the  physician  may  fancy  it  is  exaggerated  and 
due  to  the  patient  being  of  a  neurotic  habit.  This 
may  be  true,  yet  the  com.plaint  from  which  the 
patient  suffers  may  have  so  undermined  his  strength 
that  the  neurotic  habit  has  been  induced  by  his 
prolonged  suffering.  It  is  necessary  to  state  this 
because  the  presence  of  many  reflex  phenomena  is 
apt  to  be  pooh-poohed,  because  of  the  manifest 
hypersensitiveness  of  the  patient's  nervous  system.. 
There  is  no  doubt  that  in  people  of  a  neurotic  habit 
there  is  a  greater  tendency  for  reflex  phenomena  to 
be  readily  produced,  yet  the  phenomena  should  not 
on  that  account  be  ignored,  but  should  be  utilised  for 
the  purpose  of  discovering  the  lesion  if  possible,  and 
the  neurotic  tendency  being  duly  discounted,  their 
true  value  should  be  estim.ated.  However  widespread 
such  symptoms  as  pain  and  hyperalgesia  may  be, 
there  is  always  som.e  irritation  in  the  cord,  induced, 
as  a  rule,  by  some  trouble  in  the  viscera  or  external 
body  wall.  This  was  well  illustrated  in  the  following 
case,  which  was  under  m,y  observation  for  many 
years.  I  attended  the  patient  during  several  attacks 
of  rheumatic  fever  from.  1880  to  1884.  She 
developed  well-marked  symptom,s  of  aortic,  mitral, 
and  tricuspid  valvular  disease,   and  was  for  years 


Estimation  of  the  Value  of  Symptoms.       253 

very  short  of  breath  occasionally,  but  had  no  pain 
or  h3^peralgesia.  In  1895  she  began  to  complain  of 
pain,  particularly  after  meals,  referred  to  the  lower 
part  of  the  epigastric  region,  with  a  limited  area  of 
hyperalgesia.  The  pain  becam.e  very  severe,  so  that 
I  came  to  the  opinion  that  she  had  a  gastric  ulcer 
near  the  p3doric  orifice.  The  hyperalgesia  spread 
widely  round  to  the  left  chest.  She  kept  in  bed  for 
a  few  weeks,  but  began  to  go  about  her  household 
duties  before  the  pain  and  hyperalgesia  had  dis- 
appeared. She  then  began  to  have  attacks  of  pain 
in  the  chest  on  exertion,  slight  at  first,  but  gradually 
becoming  more  severe,  until  they  resembled  in  every 
respect  attacks  of  angina  pectoris.  Coincident  with 
the  pain,  hyperalgesia  appeared  in  the  chest  and 
arm..  The  distribution  of  this  h3^peralgesia,  due 
manifestl}"  to  the  heart  lesion,  coalesced  with  that 
due  to  the  gastric  ulcer,  so  that  there  was  an  exten- 
sive field  of  h}' peralgesia  em.bracing  the  left  chest 
and  abdomen,  from  the  level  of  the  second  rib  to 
below  the  umbilicus.  At  the  patient's  death  there 
were  found  the  lesions  of  the  three  valves  mentioned, 
and  an  ulcer  at  the  pyloric  orifice.  Anyone  seeing 
the  patient  after  the  development  of  the  extreme 
field  of  liyperalgesia  might  have  attributed  the  whole 
condition  to  some  such  vague  complaint  as  "  neuras- 
thenia," particularly  if  the  nature  of  the  cardiac 
lesions  were  not  detected.  I  have  seen  another  case 
with  very  severe  attacks  of  angina  pectoris  and  wide- 
spread hyperalgesia  where  no  cardiac  abnormality 
could  be  detected.  The  extraordinary  acuteness  and 
extent  of  the  sensory  phenomena  might  have  led  to 
the  surmise  that  there  was  only  a  neurasthenic  con- 
dition,   yet    at    the    post-mortem    examination    the 


254  Chapter  XXI. 

coronary  artery  was  found  almost  impermeable,  and 
the  muscle  of  the  heart  greatly  degenerated.  The 
rule  I  make  in  these  cases  is  to  recognise  the  fact 
that,  however  exaggerated  the  reflex  symptoms,  and 
however  neurotic  the  patient  may  be,  the  symptoms 
are  nevertheless  due  to  actual  affection  of  some 
viscus,  and  a  careful  consideration  of  all  the  other 
features  of  the  case  will  lead  one  to  an  approxim.ately 
correct  estimation  of  the  value  of  the  symptom,s. 

129.  Remote  Effects  of  the  Lesion.  —  Not 
only  may  the  continuance  of  a  visceral  lesion  and 
prolongation  of  suffering  lead  to  the  exhaustion  of 
the  patient's  nervous  system  (which  is  probably  the 
reason  for  the  ease  with  which  the  reflex  phenomena 
are  produced  in  m.any  people),  but  the  original 
ailment,  in  consequence  of  persistent  suffering,  may 
alter  the  whole  m.ental  balance  of  the  patient. 
Previous  to  an  illness  he  may  be  sensible,  unselfish, 
and  considerate  of  his  relatives  and  dependents, 
but  during  illness  he  may  become  utterly  selfish, 
wear  out  the  patience  of  his  children  and  dependents 
with  his  peevishness  and  want  of  consideration, 
in  order  that  his  own  requirements  and  comforts  may 
be  satisfied.  Patients  in  this  condition  are  extrem.ely 
difficult  subjects  for  diagnosis,  for  it  is  to  their 
interest  to  m.agnify  their  complaints,  and  it  is 
difficult  to  estimate  the  value  of  their  symptoms. 
This  is  particularly  the  case  if  one  searches  for 
hyperalgesia  of  skin  or  m,uscle,  for  they  readily 
complain  of  pain  and  tenderness.  To  discriminate 
the  sym.ptoms  in  such  people  the  distribution  of  the 
sensory  phenomena  (pain  and  hyperalgesia)  affords  a 
very  good  guide.  Thus  if  one  tests  for  hyperalgesia . 
of  a  heart  affection,  and  the  symptoms  are  found  to 


Estimation  of  the  Value  of  Symptoms.       255 

•extend  up  the  chest  and  over  the  clavicle,  one 
might  reject  the  synaptoms,  for  the  skin  over  the 
clavicle  as  low  as  the  second  rib  is  supplied  by  the 
fourth  cervical  nerve,  while  below  it  is  supplied 
by  the  second  thoracic,  so  that  the  extension  of 
the  hyperalgesia  from  the  second  thoracic  to  the 
fourth  cervical  is  not  conceivable.  So  it  is  in 
other  complaints ;  the  peculiar  distribution  of 
the  sensory  phenomena  in  affections  of  any  given 
organ  being  unknown  to  the  patient,  one  can  test 
his  reliability  by  noting  the  distribution  of  his 
pain  and  hyperalgesia. 

This  method  of  discrimination  is  also  to  be  used 
in  distinguishing  true  visceral  sensory  phenomena 
in  cases  of  suspected  hysteria  and  malingering.  If 
the  svmptoms  are  found  to  follow  the  distribution 
peculiar  to  one  organ,  even  if  the  patient  be  evidently 
hysterical,  then  it  may  be  concluded  that  there  is  an 
affection  of  the  viscus,  and  it  remains  to  make  care- 
ful consideration  of  the  other  factors  in  the  diagnosis 
in  order  to  estimate  what  value  the  symptoms 
possess. 

The  intensification  of  reflex  phenomena  is  par- 
ticularly noticeable  where  the  conditions  of  living 
have  reduced  the  bodily  strength,  through  worry, 
sleeplessness,  or  improper  nourishment.  I  have  been 
particularly  struck,  for  instance,  with  the  symptoms 
of  angina  pectoris  that  may  be  induced  in  young 
people  who  have  had  a  long  and  trying  period  of 
strain.  Women  who  work  hard  for  their  living,  or 
who  look  after  household  duties  during  the  day,  and 
have  to  attend  an  invalid  parent  or  ailing  child 
during  the  night,  who  are  frequently  disturbed  in 
sleep,  or  who  pass  the  greater  part  of  the  night  in 


256  Cha'pter  XXI, 

constant  attendance,  become  gradually  exhausted, 
and  the  struggle  may  go  on  until  an  attack  of  pain 
in  the  chest  imperatively  calls  attention  to  the 
exhausted  heart.  In  such  people  the  attacks  of 
angina  pectoris  may  be  extremely  severe,  and  the 
hyperalgesia  may  be  widespread,  affecting  both 
sides  of  the  chest  (the  left  breast  particularly  often 
becoming  extremely  tender),  and,  it  may  be,  the 
neck,  particularly  the  left  sterno-mastoid  and 
trapezius  muscles. 

In  estimating  the  value  of  the  symptoms  in  such 
cases  the  history  of  the  patient's  life  gives  an 
indication,  and  one  can  then  recognise,  with  assur- 
ance, the  condition  of  the  heart  that  has  provoked 
these  manifestations. 

Similar  exaggerated  symptoms,  having  a 
peculiar  distribution,  may  arise  should  any  other 
organ  be  affected  ;  as  in  stomach  affections,  a  slight 
indigestion  may  give  rise  to  such  symptoms  as  to 
make  it  difficult  to  tell  whether  some  more  serious 
condition,  as  gastric  ulcer,  may  not  be  present. 

In  doubtful  cases  one  feature  when  present 
may  be  taken  as  a  rule  to  distinguish  an 
affection  of  an  organ  from  some  general  nervous 
manifestation,  that  is  the  viscero-motor  reflex.  Un- 
fortunately this  sym.pt cm.  is  practically  limited  to 
affections  of  the  abdominal  organs,  and  needs  to  be 
sought  for  with  care,  lest  a  too  susceptible  super- 
ficial reflex  be  started.  But  when  detected  it  may 
be  looked  upon  as  dem.onstrating  the  presence  of 
some  visceral  trouble. 

130.  Relation  of  Symptoms  arising  from 
different  Causes. — When  a  patient  presents  him.- 
self  one  may  be  able,  on  physical  examination,  ta 


Estimation  of  the   Value  of  Symptoms.       257 

detect  some  abnormal  condition  to  Avhich  one  can 
refer  with  certainty  the  cause  of  the  patient's 
suffering.  It  ma}^  happen,  however,  that  w^e  detect 
an  abnormahtv^  having  no  direct  bearing  upon  the 
complaint  of  the  patient,  and  in  the  absence  of  one 
having  sucli  a  direct  bearing,  there  is  too  often  a 
tendency  to  refer  the  patient's  complaint  to  the  pres- 
ence of  the  recognisable  abnormality.  There  is  no 
doubt  that  symptoms  may  be  provoked  by  lesions 
remote  from  the  place  where  they  are  ex- 
perienced, as  in  referred  pain,  and  there  is  no  doubt 
that  many  other  symptoms  may  be  produced  by 
lesions  of  remote  organs,  as  in  the  widespread  effects 
of  kidney  disease.  But  keeping  all  this  in  view,  there 
is  still  need  of  a  wise  discretion  in  estimating  the 
influence  of  lesions  in  which  there  is  no  recognisable 
connection  with  the  symptoms.  Thus  epileptic 
attacks  may  be  brought  on  by  affections  of  the  heart 
as  in  heart-block  (Adams-Stokes  syndrome),  where 
the  left  ventricle  becomes  so  slow  in  its  action  that 
the  brain  does  not  receive  a  sufficient  supply  of  blood. 
In  consequence  of  this  anaemia  the  patient  may  faint 
or  have  an  epileptic  seizure.  The  well-recognised 
connection  between  a  heart  abnorniality  and  an 
epileptic  attack  in  this  particular  instance  has  led 
to  the  assumption  that,  if  a  patient  has  epilepsy 
and  at  the  same  time  has  some  affection  of  the  heart 
such  as  irregular  action,  there  is  a  connection 
between  the  two.  Under  such  circunistances  it  is 
necessary  to  recognise  the  nature  of  the  irregularity, 
and  as  it  is  now  possible  to  demonstrate  with  pre- 
cision the  different  forms  of  heart  irregularity, 
the  recognition  of  the  particular  form  of  irregular 
heart   action    at   once   permits   of   determining   the 


258  Chapter  XXL 

probabilities  of  the  heart  being  the  cause  of  the 
epileptic  attack  in  any  given  condition.  Irregular 
action  of  the  heart  being  so  common,  the  occurrence 
of  epilepsy  is  in  the  majorit}^  of  cases  due  to  an 
independent  affection,  and  there  is  no  casual 
relation  necessarily  present  between  the  two 
conditions. 

I  have  already  referred  to  errors  arising  from 
attributing  the  cause  of  symptoms  to  some  demon- 
strable structural  affection  which  may  be  merely 
coincident    or    independent. 

It  is  impossible  to  lay  down  rules  applicable  to 
all  cases,  and  I  write  this  in  order  that  the  subject 
should  in  every  case  receive  consideration,  since  the 
recognition  of  the  possibility  of  error  may  prevent 
the  error  being  made. 

131.  The  Bearing  of  Symptoms  on  Prognosis. — 
Of  all  branches  of  medicine  there  is  none  which 
has  received  so  little  real  consideration  as  the  matter 
of  prognosis.  The  subject  itself  is  one  which  has  to 
be  considered  in  nearly  every  case  that  comes  under 
the  notice  of  a  medical  man.  Its  importance  is 
a,ppreciated  in  all  stages  of  life,  and  the  just  con- 
sideration of  the  meaning  of  symptoms  is  of  cardinal 
importance  in  regard  to  the  patient's  future. 

In  addition  to  recognising  the  meaning  of  any 
abnormal  sign  or  symptom,  we  should  endeavour  to 
acquire  a  knowledge  of  what  bearing  it  has  upon  the 
future  history  of  the  patient.  This  knowledge  can 
only  be  obtained  by  watching  how  patients  exhibit- 
ing the  abnormality  withstand  the  storm  and  stress 
of  life.  This  should  be  a  special  object  of  every 
general  practitioner,  for  it  is  he  who  has  the  oppor- 
tunity  of   watching   individual   cases   over   a   long 


Estimation  of  the  Value  of  Symptoms.       259 

period  of  years,  and  of  estimating  the  bearing  of 
any  abnormality  on  the  patient's  future  hfe. 

I  am  afraid  that  our  profession  as  a  body  does 
not  sufficiently  recognise  its  responsibility  in  regard 
to  prognosis.  When  an  individual  submits  himself  for 
an  opinion,  he  does  so  with  such  implicit  confidence 
that  the  verdict  given  m.ay  alter  the  whole  tenor  of 
his  life.  He  may,  for  instance,  be  seeking  to  enter 
some  profession,  when  a  preliminary  medical  exam- 
ination reveals  what  the  medical  man  takes  to  be  an 
abnormality.  An  imperfect  knowledge  of  its  nature 
may,  and  unfortunately  often  does,  lead  to  its  being 
regarded  as  presaging  possibly  grave  consequences, 
and  the  candidate  is  rejected.  He  is  thus  shut  off 
from  the  prospect  of  his  chosen  calling,  and,  know- 
ing the  reason  of  his  rejection,  passes  through  life 
uneasily  apprehensive  of  some  impending  disaster, 
whilst  all  the  time  the  supposed  abnormality  may  be 
a  sign  of  little  or  no  consequence. 

If  we  look  at  an  insurance  form  we  realise  the 
hardships  to  which  applicants  are  exposed.  "  Is  the 
pulse  regular  ?  "  "  Are  the  sounds  of  the  heart 
pure  ?  "  "Is  the  urine  free  from  albumen  ?  "  When 
such  questions  are  answered  in  the  negative  the 
applicant  may  nevertheless  be  perfectly  healthy,  yet 
is  either  rejected  or  is  penalised  for  life  by  having 
to  paj^  a  higher  premium,  and,  in  addition,  he  is 
burdened  with  the  consciousness  of  infirmity. 

I  dwell  on  this  matter  with  some  insistence, 
because  I  have  known  of  so  many  instances  in 
which  gross  injustice  has  been  done  to  individuals, 
not  only  from  a  pecuniary  aspect,  but  in  having 
imposed  upon  them  great  expense,  unnecessary 
treatment,  and  mental  disquiet,  because  the  meaning 


260  Chapter  XXI. 

and  prognostic  significance  of  some  simple  symptom 
had  not  been  recognised. 

A  serious  responsibility  is  thrown  upon  every 
practitioner  at  times  in  advising  upon  other  ques- 
tions. Should  a  man  give  up  his  business  ?  is  a 
question  upon  which  advice  is  constantly  sought ;  and 
whether  the  individual  be  a  statesman  or  a  labourer, 
the  greatest  care  is  necessary  in  formulating  the 
answer.  "  Should  a  wom.an  with  som.e  heart  affection 
m.arry  ?  "  or,  "  If  she  be  pregnant,  should  the  preg- 
nancy be  allowed  to  proceed  ?  "  are  problems  that 
every  general  practitioner  at  one  time  or  another  will 
have  to  m.eet  ;  and  if  he  seeks  for  guidance  in  the 
text-books,  he  finds  merely  vague  views  which  he 
cannot  apply  to  the  individual  case.  This  fact  alone 
should  arrest  the  attention  of  the  profession,  and 
make  it  conscious  how  insufficient  are  the  indications 
for  an  intelligent  prognosis. 

In  estimating  the  value  of  any  abnorm.al  sign, 
or  in  determining  the  condition  of  the  patient,  a 
clear  idea  must  be  obtained  of  the  mechanism  by 
which  any  given  sym.ptom  is  produced,  and  of  the 
effects  that  the  underlying  lesion  has  upon  the 
economy.  It  is  impossible  to  give  here  indications 
that  would  be  of  value,  partly  because  the  subject 
traverses  the  whole  field  of  clinical  medicine  and 
partly  because  I  am  not  com.petent  to  deal  with  the 
m.atter,  being  only  impressed  with  the  importance 
of  the  subject  and  the  necessity  for  its  further  con- 
sideration. So  far  as  my  experience  goes,  I  can  only 
say  that  one  should  never  base  a  prognosis  upon  the 
presence  of  a  single  sym.ptom,  but  should  carefully 
investigate  the  effect  of  any  abnorm.al  sign  on  the 
functional    efficiency    of   the   organ    and   upon   the 


Estimation  of  the  Value  of  Symptoms.        261 

economy  as  a  whole.  The  presence  of  albumen  in 
the  urine  is  often  a  sign  of  variable  import.  In 
many  cases  it  is  a  sign  of  great  gravity,  and  this 
being  recognised,  it  is  too  often  regarded  as  being 
invariably  a  serious  matter.  It  is  now  recognised 
that  its  significance  depends  on  the  conditions  induc- 
ing it,  and  it  may  appear  when  there  is  no  serious 
affection  of  the  kidney,  or  when  the  kidney  affection 
is  of  such  a  nature  that  it  may  have  little  effect 
upon  the  system.  Cases  of  albuminuria  should  not 
therefore  be  hastily  condemned  until  a  complete 
review  of  the  whole  circumstances  of  the  case,  such 
as  the  history  of  the  illness,  tlie  condition  of  the 
other  constituents  in  the  urine  and  their  effect  upon 
the  circulator}"  system,  has  been  made.  In  the  same 
waj^  the  presence  of  a  cardiac  murmur  or  irregu- 
larity, or  even  an  attack  of  angina  pectoris,  should 
never  be  considered  as  affording  grounds  for  a  grave 
prognosis  until  the  whole  circumstances  of  the  case 
are  taken  into  consideration.  I  mention  these  in- 
stances merely  as  indications  as  to  what  course  to 
pursue  when  doubts  arise  as  to  the  significance  of 
any  abnormal  sign. 

The  symptoms  which  arise  reflexly  in  like 
manner  have  to  be  carefull}^  weighed.  Intensity  of 
suffering  may  have  no  relation  to  the  gravity  of  the 
complaint.  Toothache  causes  no  anxiety  as  to  the 
prognosis,  though  the  immediate  suffering  is  severe. 
Were  the  cause  of  the  pain  not  so  easily  recognised 
the  agonising  distress  would  at  times  be  viewed 
with  the  gravest  anxiety.  Extreme  suffering  from 
some  trivial  disease  may  be  found  among  the 
symptoms  of  many  organs.  When  it  is  recognised 
that  the  most  agonising  pains  are  associated  with  the 


262  Cha'pter  XXI. 

contraction  of  non-striped  muscular  fibres,  it  will 
be  realised  that  the  cause  inducing  a  contraction 
capable  of  calling  forth  violent  pain  may  be  of  the 
most  varied  kinds,  trivial  as  well  as  im,portant. 
Even  in  the  matter  of  angina  pectoris  the  violence  of 
the  pain  bears  no  necessary  relation  to  the  gravity 
of  the  heart  complaint.  In  many  cases  the  only 
sensation  brought  on  by  exhaustion  of  the  heart 
muscle  may  be  limited  to  a  mere  sense  of  constriction, 
and  this,  if  properly  appreciated,  may  indeed  be 
the  one  sign  which  calls  attention  to  the  serious 
condition  of  the  heart.  I  have  repeatedly  been  con- 
sulted by  elderly  people  for  this  sense  of  constric- 
tion across  the  chest  when  they  exerted  themselves, 
and  in  many  cases  it  was  the  earliest  symptom  that 
heralded  the  termination  of  the  patient's  life.  On 
the  other  hand,  some  of  the  most  violent  attacks  of 
angina  pectoris  have  occurred  in  people  in  whom  the 
exhaustion  of  the  heart  was  but  temporary,  and  the 
restoration  of  reserve  force  resulted  in  a  complete 
cessation  of  pain  and  in  permanent  recover}^ 
Between  these  extremes  there  are  many  intermediate 
forms,  and  it  needs  a  careful  inquiry  into  all  the 
circumstances  before  a  definite  prognosis  can  be 
given. 

In  regard  to  the  reflex  phenomena  the  tendency 
to  the  exaggeration  of  symptoms  by  people  with  a 
hypersensitive  nervous  system  must  always  be 
borne  in  mind. 

132.  The  Bearing  of  Symptoms  on  Treatment. — 
The  due  appreciation  of  the  mechanism  by  which 
sym.ptoms  are  produced  has  a  profound  influence  on 
treatment.  It  is  often  stated  that  treatment  has  to 
be  symptomatic,  that  is,  the  symptoms  are  to  be 


Estimation  of  the  Value  of  Sympto7ns.       263 

treated  because  the  nature  of  the  affection  inducing 
those  symptoms  cannot  be  detected.  Whole  sj^stems 
of  treatment  are  based  upon  this  idea,  and  though 
at  times  we  may  be  forced  to  accept  this  hne,  it 
should  always  be  done  with  regret  at  our  incapacity 
to  recognise  the  underlying  cause  of  the  suffering.  A 
constant  endeavour  to  make  out  the  meaning  of  these 
symptoms,  which  have  perforce  to  be  treated 
without  knowledge  of  their  cause,  will  gradually 
diminish  the  number  of  patients  who  have  to  be 
treated  symptomatically. 

As  pain  is  the  most  common  complaint  from 
which  so  many  suffer,  its  relief  is  an  aim  of  our 
treatment.  But  it  should  never  be  supposed  that  the 
assuagement  of  pain  is  the  only  object.  It  has 
become  stereotyped  to  say  "  remove  the  cause,"  and 
if  this  advice  had  not  become  so  much  of  a  platitude 
more  attention  might  be  given  to  the  "  search  for  the 
cause."  The  recognition  of  the  cause  can  only  be 
attained  in  the  majority  of  sufferers  by  a  recognition 
of  the  mechanism  by  which  the  suffering  is  produced. 
Recognising,  for  instance,  that  contraction  of  non- 
striped  muscle  produces  a  referred  pain,  the  know- 
ledge of  how  the  pain  is  produced  leads  to  the  recog- 
nition of  the  hollow  viscus  producing  it.  There  must 
be  an  abnormal  stimulus  exciting  the  muscle  to  con- 
traction, and  experience  leads  us  to  conclude  what 
is  the  most  common  cause  likely  to  produce  the  stimu- 
lation in  a  particular  viscus.  A  pain  with  accom- 
panying phenomena  located  in  a  certain  region  in- 
forms us  that  the  stimulus  arises  from  the  gall-duct 
or  the  ureter.  Experience  tells  us  that  a  gall-stone  or 
renal  calculus  is  the  most  frequent  cause.  The 
absence  of  symptoms  indicative  of  any  other  lesion 


264  Chapter  XXI. 

confirms  this  view.  On  recognising  that  this  is  the 
cause  the  question  arises  :  can  we  remove  it  ?  In 
the  vast  majority  of  cases  this  is  only  possible  b}^ 
surgical  operation,  and  the  question  of  the  propriety 
of  this  procedure  has  to  be  considered.  If,  as  is  often 
the  case,  this  proves  inadvisable,  then  the  treatment 
must  proceed  on  other  lines,  and  the  recognition  of 
the  mechanism  by  which  the  pain  arises  again  gives 
indications.  As  it  is  manifestly  due  to  the  strong 
contraction  of  non-striped  muscle,  measures  that  will 
relax  the  contraction  of  the  muscle  will  naturally  be 
the  remedy  in  this  particular  case  for  the  time  being. 

On  the  other  hand,  if  the  pain  be  aroused  by 
some  hollow  muscular  organ,  where  it  is  possible  by 
simple  means  to  remove  the  cause  that  stimulates 
the  contraction,  to  this  end  treatment  should 
be  primarily  directed.  If,  for  instance,  the 
indications  point  to  the  pain  arising  from  painful 
peristalsis  of  the  bowel,  the  inquiry  will  proceed  to 
find  out  the  probable  nature  of  the  stimulus.  If 
there  has  been  a  history  of  constipation,  or  incom- 
plete evacuation  of  the  bowel,  the  retention  of 
scybalous  masses  is  suggested  as  the  cause  of  the 
peristalsis,  and  the  treatment  will  be  guided  to 
measures  that  will  lead  to  evacuation.  So  also  with 
regard  to  any  other  viscus  that  can  be  emptied,  the 
recognition  of  the  nature  of  the  symptom.s  affording 
the  best  guide  for  a  rational  and  effective  treatment. 

In  an  organ,  such  as  the  heart,  that  cannot  have 
the  cause  of  the  sufi^ering  removed  by  some  mechani- 
cal process,  the  consideration  of  the  conditions  that 
induce  the  sym.ptoms  leads  to  a  rational  guide  in 
treatment.  As  I  have  pointed  out,  any  symptom 
of  suffering  points  to  an  exhaustion  of  the  reserve 


Estimation  of  the   Value  of  Symptoms.       265 

iorce,  whatever  be  the  nature  of  the  functional 
exhaustion  or  structural  lesion.  The  recognition  of 
this  indicates  tliat  treatment  in  the  first  instance 
must  be  directed  to  the  restoration  of  this  reserve 
force,  and  this  can  be  done  when  consideration  of 
the  factors  inducing  the  exhaustion  are  appreciated, 
such  as  over-work,  worry,  sleeplessness,  or  the  ham- 
pering effect  of  some  organic  lesion.  This  demands 
careful  investigation  into  the  special  features  of  each 
individual  case. 

These  remarks  may  seem  so  evident  as  to  be 
altogether  unnecessary,  as  everyone  recognises  them. 
But  though  as  a  matter  of  theory  they  are  the 
commonest  of  platitudes,  as  a  matter  of  practice 
they  are  often  neglected.  If  we  consider  the 
matter  in  relation  to  the  treatment  of  heart 
affections,  for  instance,  it  would  be  found  that,  what- 
ever the  nature  of  the  heart  failure,  a  routine  method 
of  treatment  is,  with  few  exceptions,  invariably 
adopted.  Thus  heart  failure  is  supposed  to  demand 
what  are  called  "  heart  tonics,"  and  the  usual 
treatment  is  to  prescribe  the  tonic  which  is  dictated 
by  the  fancy  of  the  physician  or  by  the  fashion  of 
tlie  day.  In  our  inquiries  into  systems  of  treatment, 
such  as  are  elaborated  at  phxces  hke  Nauheim,  it 
will  be  found  that  routine  methods  are  employed, 
after  few  or  no  discriminating  inquiries  into  the 
pecuhar  features  of  each  case.  One  could  indefinitely 
extend  ilkistrations,  drawn  from  other  systems,  where 
rule  of  tluimb  treatment  is  followed,  to  the  neglect 
of  the  simple  and  obvious  methods  suggested  by  the 
careful  appreciation  of  the  meaning  of  symptoms. 

I  have  already  pointed  out  that  treatment  may 
be   a  factor  in   diagnosis— so-called   diagnosis   "  ex 


266  Chaj)ter  XXI. 

juvantibus  " — the  manner  in  which  symptoms  react 
to  treatment  being  often  a  useful  help,  as,  for  in- 
stance, the  use  of  mercury  or  iodide  of  potassium  in 
suspected  cases  of  syphilis.  But  it  is  necessary  also 
to  appreciate  when  possible  the  manner  in  which  the 
treatment  acts.  It  must  be  the  experience  of  every- 
one who  has  seen  a  large  number  of  cases  of  stomach 
affections,  that  many  cases  of  great  suffering,  where 
there  is  manifest  structural  lesion,  obtain  relief  by 
some  simple  remedy  or  change  in  diet.  Thus  in 
pyloric  stenosis  with  dilatation  of  the  stomach  the 
patient  may  have  suffered  for  a  long  period,  and 
some  simple  remedj^,  as  bicarbonate  of  soda,  may 
give  instant  relief  and  freedom  from  suffering  for  a 
long  time.  So  also  a  change  in  the  diet  may  have 
the  same  result.  Too  often  such  remarkable  experi- 
ences are  mistaken  by  physician  and  patient  as 
evidences  of  the  curative  value  and  potency  of  the 
drug  or  system  of  diet,  and  so  we  get  the  exaggerated 
praises  of  different  drugs  and  systems  so  common 
nowadays.  If  it  be  recognised  that  some  constituent 
was  present  in  the  stom.ach  which  occasioned  the 
sufferings  of  the  patient,  and  that  the  drug  had 
neutralised  its  effects,  or  the  change  of  diet  had  pre- 
vented its  formation,  it  would  have  led  to  a  truer 
appreciation  of  the  benefits  obtained  by  the 
treatment.  It  cannot  be  too  strongly  insisted 
upon  that  the  reflex  symptoms,  which  are  those  that 
are  thus  "  cured,"  may  arise,  not  from,  the  actual 
lesion,  but  from,  a  susceptibility  to  stimulation, 
or  from  some  agent  capable  of  inducing  an  adequate 
stim,ulation,  and  that  the  symptoms  give  no  clue 
to  the  nature  of  the  stimulation  or  to  the  agent 
causing  it. 


Estimation  of  the  Value  of  Symptoms.       267 

The  recognition  of  the  meaning  of  the  reflex 
phenomena  is  of  much  use  in  so  many  ways  that  it 
is  scarcely  possible  to  do  more  than  indicate  certain 
phases  of  their  value.  The  muscular  contractions 
and  hyperalgesia  are  always  indications  that  some 
active  process  is  going  on.  In  cases  of  gastric  ulcer, 
for  instance,  the  treatm.ent  may  have  been  so  success- 
ful that  the  patient's  sufferings  are  relieved  and  a 
"  cure  "  is  said  to  have  resulted.  But  a  careful 
examination  of  the  left  rectus  muscle  may  reveal 
tenderness  of  its  upper  division  with  increased  tone  ; 
and  these  symptoms  indicate  that  the  stom.ach  lesion 
is  still  so  active  that  it  keeps  up  an  irritable  focus  in 
the  cord,  and  give  indication  that  the  treatment 
should  be  continued  if  a  permanent  recovery  is  to  be 
attained.  Occasionally  one  meets  Avith  cases  where 
this  viscero-motor  reflex  has  been  recognised  and 
taken  as  the  factor  needing  treatment.  In  gall-stone 
disease,  when  there  is  present  the  tell-tale  sign  of 
contracted  muscles  in  the  epigastrium,  energetic 
means,  as  b^-ths,  electricity,  massage,  are  frequently 
employed  to  reduce  the  "  hardness  "  of  the  belly  wall! 

The  conception  of  the  nature  of  the  reflex 
phenomena  may  give  a  more  direct  aim  to  our 
therapeutic  endeavours.  I  have  already  pointed 
out  how  the  suffering  in  stom.ach  affections  may  be 
due  to  the  accidental  presence  of  an  agent  that  is 
capable  of  producing  pain,  and  that  remedies  may 
neutralise  the  effect  of  the  agent  without  modifying 
the  disease  process.  It  is  conceivable  that  an  effect 
may  be  produced  in  other  ways,  whereby  treatment 
may  influence  the  reflex  symptoms  at  some  portion 
of  the  chain  between  the  lesion  and  the  mental 
conception  of  tlie  suffering.     Thus  a  drug  may  act 


268  Chapter  XXI. 

upon  the  muscular  spasm  when  it  causes  pain,  or  it 
may  act  upon  the  spinal  cord  at  the  level  where  the 
visceral  nerve  stimulates  the  sensory  nerve.  It  is 
just  possible  that  it  is  here  the  relief  is  obtained  in 
certain  forms  of  counter-irritation.  Thus  I  have  seen 
a  patient  with  a  pyloric  ulcer  of  the  stomach  obtain 
relief  by  a  blister  on  the  epigastrium  over  the  limited 
area  in  which  the  pain  was  felt.  This  blister  did  not 
directly  affect  the  ulcer,  because  the  ulcer  did  not 
lie  at  the  same  level  {see  Fig.  11).  Nor  could  one 
imagine  that  any  reflex  effect  was  produced  in  the 
ulcer  itself.  It  seems  more  probable  that  the 
stimulus  from  the  skin  affecting  directly  the  peri- 
pheral distribution  of  the  sensory  nerve  prevented 
by  some  inhibiting  process  the  stimulus  from  the 
viscus  passing  to  the  sensory  cells  in  the  spinal  cord. 
This  seems  the  m.ore  reasonable,  because  it  was 
found  that  on  the  healing  of  the  blister  the  old  pain 
from  the  ulcer  returned,  but  if  the  blistered  skin 
were  kept  raw  by  the  application  of  some  ointment 
the  pain  from  the  ulcer  was  subdued..  This  view 
receives  support  from  the  result  of  recent  researches 
of  Sherrington,  by  which  it  has  been  shown  that 
nerve  paths  may  be  stimulated  from  a  variety  of 
sources,  but  that  of  several  contemporaneous  stimuli 
one  stimulus  may  be  received  and  the  others 
inhibited. 


(     269 


APPENDIX    T. 

MR.    LIGAT   ON   HYPERALGESIA   IN 
ABDOMINAL    DISEASES. 

It  has  long  been  to  me  a  matter  of  surprise  that 
surgeons  should  have  failed  to  grasp  the  significance 
of  the  symptoms  provoked  by  visceral  disease, 
because  they  have  had  unrivalled  opportunities  for 
observation,  and  for  verifying  the  relations  between 
symptoms  and  disease.  The  comparative  safety  of 
an  exploratory  operation  has  led  surgeons  to  employ 
this  method  for  diagnostic  purposes,  and  they  have, 
in  consequence,  neglected  the  information  to  be 
derived  from  the  stud}^  of  symptoms.  In  a  case  of 
doubt,  and  doubtful  cases  are  not  infrequent,  the 
surgeon,  in  place  of  minutely  investigating  aU  the 
phenomena,  opens  up  the  patient  and  looks  inside. 
It  is  for  this  reason  that  the  s^^mptoms  so  plainly 
perceptible  on  the  external  bod}^  wall  are  overlooked 
or  described  in  language  so  vague  that  it  is  evident 
that  the  surgeon  has  never  really  grasped  their 
significance. 

It  was  tlierefore  a  pleasant  surprise  when  I  read 
the  results  of  one  surgeon  wlio  conducted  an  in- 
vestigation on  the  lines  indicated  in  this  book,  and 
it  was  gratifying  for  me  to  find  liow  completely 
he  verified  tlie  results  I  liad  obtained  in  the  rehitively 
few  opportunities  I  had  of  demonstrating  the  relation 


270  Appendix  I. 

between  the  symptoms  and  the  disease.  Mr.  Ligat's 
paper  was  published  in  "  The  Practitioner "  for 
August,  1916,  and  I  would  refer  my  readers  to  that 
article  for  a  detailed  account  of  one  of  the  most 
convincing  and  helpful  clinical  studies — too  rare, 
unfortunately,  in  medicine  or  surgery. 

In  this  article  Ligat  deals  mainly  with  the 
hyperalgesia  of  the  skin  of  the  abdominal  wall. 
His  method  of  exploration  in  any  given  case  is  to 
"  grasp  the  skin  and  subcutaneous  tissue  firmly 
between  finger  and  thumb,  and  draw  them  away 
from  the  deeper  layers  of  the  abdominal  wall.  If 
a  hyperalgesic  area  be  present,  the  patient  winces, 
and  one  can  tell,  by  the  patient's  expression,  when 
such  an  area  is  being  stimulated."  The  facial 
expression  should  be  watched,  as  when  a  tender 
area  is  thus  treated,  a  sudden  expression  of  pain 
passes  over  the  face,  "  converting  a  subjective 
symptom  virtually  into  an  objective  sign." 

In  attacks  of  bihary  or  renal  colic  or  in  a 
perforating  gastric  ulcer  or  appendix  the  pain  is  so 
great  and  the  hyperalgesia  may  be  so  severe  and 
widespread  that  a  precise  and  definite  result  cannot 
always  be  obtained.  It  is  in  less  acute  cases  and  in 
clironic  cases  that  instructive  hyperalgesic  areas, 
their  maximum  points,  spread,  and  limitation  can 
best  be  perceived. 

The  following  diagram,  showing  definite  areas  of 
hyperalgesia  (Fig.  19),  from  Ligat's  paper  gives  the 
results  of  his  observations.  The  areas  are  based  on 
operations  in  54  cases  of  choli  cystitis,  of  which  41 
give  the  characteristic  area  in  the  figure.  In  243 
consecutive  cases  of  appendicitis,  195  give  the 
definite  area.     In  39  cases  of  tubal  disease,  20  give 


Appendix  I. 


271 


Fig.   19. 


Diagrammatic  illustration  of  the  hyperalgesic  points,  with  tj^pical 
spread.  The  length  of  the  line  denotes  the  intensity  of  the  hyperalgesia, 
xiot  hxteral  spread.     Note  there  is  more  downward  than  u[)ward  spread. 

1.  Shows  hyperalgesic  area  when  present  in  gall-bladder  lesions. 

2.  Shows  hyperalgesic  area  when  present  in  appendix  lesions. 

3.  Shows  hyperalgesic  area  when  present  in  right  Fallopian  tube  lesions. 

4.  Shows  hyperalgesic  area  when  present  in  gastric  and  duodenal  ulcers. 

5.  Shows  hyperalgesic  area  when  present  in  small-gut  lesions. 

6.  Shows  hyperalgesic  area  when  i)resent  in  great-gut  lesions. 

7.  Shows  hyperalgesic  area  whtn  present  in  left  Fallopian  tube  lesions. 


272  Appendix  I. 

the  area.     In  80  cases  of  gastric  ulcer,  50  give  the 
characteristic   area. 

In  his  recorded  cases  of  intestinal  operations 
the  symptoms  are  not  so  clear  and  simple  as  in  the 
lateral  organs,  nevertheless  they  bear  out  in  a 
remarka,ble  manner  the  region  of  pain  and  hyperal- 
gesia shown  in  my  Figure  8,  as  will  be  seen  by 
comparing  that  figure  with  the  areas  4,  5,  and  6  in 
Fig.  19. 


(     273     ) 


APPENDIX    II 

CLINICAL    INVESTIGATION. 

A  great  many  medical  men  desire  to  investigate 
fields  of  medicine  that  are  obscure.  This  desire 
sensibly  diminishes  with  advancing  years.  This 
diminution  is  not  due  to  the  successful  accomplish- 
ment of  investigation,  but  rather  to  the  sense  of 
comparative  failure  and  ineffectiveness  that  has  come 
after  years  spent  in  this  work. 

If  we  inquire  into  the  reason  for  this  dis- 
appointment we  shall  find  it  is  due  to  a  wrong 
conception  of  what  constitutes  medical  research. 
During  the  last  half  centur}^  the  great  discoveries 
have  come  mainly  from  researches  carried  on  in 
laboratories,  and  to  a  lesser  degree  in  hospital 
wards.  In  consequence  there  has  arisen  the  idea 
that  it  is  only  in  such  places  that  research  work  can 
be  carried  on.  When  the  ardent  youth  desires  to  do 
what  is  called  "  orginal  research  "  he  naturally 
seeks  the  guidance  of  some  one  who  is  himself 
engaged  in  research  work.  The  advice  he  receives 
is  coloured  by  the  experience  of  the  adviser,  and 
as  this  is  again  limited  by  the  adviser's  somewhat 
narrow  horizon,  the  enquiring  youth  has  suggested 
to  him  some  academic  problem  that  has  little 
bearing  on  practical  medicine,  and  unlikely  to  yield 
an}^  fruitful  result.  Had  it  been  of  much  promise 
the  adviser  himself  would  long  ago  have  undertaken 


274  Appendix  II. 

it.  Many  youths  full  of  hope  who  enter  on  a  course 
of  research  find,  after  a  few  j^ears,  how  profitless 
has  been  the  time  thus  spent,  and  are  discouraged 
for  undertaking  research  work  in  their  later  years. 

Unless  he  merely  wants  to  learn  methods  or  to 
assist  an  experienced  observer  no  young  man  should 
start  out  with  the  idea  of  undertaking  research. 
He  must  wait  till  he  has  studied  disease  processes 
so  far  as  to  be  able  of  himself  to  recognise  where 
knowledge  is  deficient.  In  being  guided  by  another's 
experience  he  fails  to  grasp  the  need  for  the  work. 
I  have  been  struck  over  and  over  again  by  the  failure 
of  research  workers  to  obtain  any  satisfactory 
result  after  long  periods  of  patient  labour,  and  I  have 
frequently  observed  this  failure  in  men  whom  I 
m3^self  have  advised.  The  reason  for  this  is  that  the 
experienced  observer  recognises  a  certain  field  that 
needs  exploring.  He  has  come  to  this  conclusion 
because  of  a  great  number  of  experiences  which  have 
forced  the  need  upon  him.  When  then  he  advises 
an  inexperienced  individual  to  follow  a  certain  line 
he  fails  to  convey  to  that  individual  the  reasons 
that  govern  his  advice.  Failing  to  grasp  the  full 
significance  of  the  suggested  work  he,  the  young 
student,  does  not  realise  its  importance,  nor  does  he 
see  the  goal,  and  hence  he  lacks  the  incentive  to 
pursue  it  with  that  intensity  of  mind  which  the  true 
research  student  requires. 

Hitherto  a  far  too  restricted  view  has  been  taken 
of  the  opportunities  and  methods  of  research  in 
medicine.  The  workman's  laboratory  and  the  hos- 
pital wards  have  hitherto  dominated  all  conceptions 
of  research,  and  this  has  led  to  a  deplorable  narrow- 
ness of  outlook  ;  indeed,  so  restricted  is  this  view 


Appendix  II.  275 

that  al]  the  teaching  exponents  of  medicine  go  so 
far  as  to  say  that  research  in  cHnical  medicine  has 
almost  reached  its  hmit  until  some  new  mechanical 
device  is  discovered,  or  that  it  is  only  in  the  labora- 
tory that  true  research  can  be  achieved.  This 
foolish  conception  accounts  for  the  sudden  and 
universal  popularity  of  any  new  instrument  or 
method — a  popularity  which,  however,  is  evanescent, 
because  sooner  or  later  its  field  of  usefulness  is  found 
to  be  very  restricted.  This  erroneous  conception  of 
medical  research  accounts  greatly  for  the  barrenness 
which  has  characterised  modern  medicine.  That 
there  are  great  fields  unexplored,  which  need  nothing 
but  the  ordinary  methods  possessed  by  everj^  doctor, 
has  not  yet  reached  the  consciousness  of  the  pro- 
fession. To  recognise  these  fields  which  are  essential 
to  medical  progress,  we  have  but  to  consider  how 
investigation  has  been  pursued  in  the  past,  and  is 
still  being  pursued.  Looking  at  the  matter  broadl}^ 
the  prosecution  of  research  in  wards  and  laboratories 
deals  mainly  with  disease  after  it  has  invaded  the 
body  and  caused  such  alteration  or  destruction  of 
tissue  as  to  have  produced  a  physical  sign,  or  the 
disease  is  studied  after  death.  Attention  has  been 
devoted  to  finding  out  all  about  these  physical  signs 
during  life  and  a  close  investigation  into  them  after 
death.  Thus  the  later  stage  of  disease,  and  the 
post-mortem  appearances,  have  been  the  main  object 
of  investigation,  and  this  restricted  outlook  on 
disease  has  shaped  the  course  of  medical  study. 
Thus  we  see,  for  instance,  all  the  experienced 
physicians  at  a  hospital  devoting  their  time  to  the 
study  of  disease  in  the  wards,  where  patients  liave 
the  disease  so   far   advanced   as  to   show   ph\'8ical 


276  Appendix  II. 

signs,  many  of  them  dying  of  their  disease.  Here 
all  the  energies  of  research  are  concentrated — the 
experienced  physician,  his  assistants,  his  laboratories, 
and  so  forth.  Thus  disease  in  its  later  stage  has 
absorbed  the  attention  of  investigation  in  the  past. 
What  of  the  earlier  stages  ?  Surely  it  is  here  that 
the  physician's  energies  should  be  exerted  to  the  full, 
for  if  disease  cannot  be  prevented,  the  next  best 
thing  is  to  recognise  it  at  its  earliest  stage,  before 
it  has  irreparably  damaged  the  tissues,  and  while 
yet  it  is  amenable  to  treatment.  The  early  stage  of 
disease  has  never  yet  formed  the  subject  of  accurate 
and  painstaking  observation.  Such  opportunities 
as  the  hospital  physician  has  for  its  study  are  in  the 
out-patient  department,  and  then  the  conditions 
are  so  unfavourable  that  no  real  attempt  at  the 
carrying  on  of  research  work  here  is  made.  The 
sj^mptoms  of  the  early  stages  of  disease  are  so  subtle 
and  elusive  that  what  little  is  known  of  them  can 
only  come  through  years  of  patient  investigation. 
Yet  this  phase  of  disease,  found  mainly  in  out- 
patients, is  handed  over  to  the  least  experienced 
members  of  a  hospital  staff  at  a  time  when  their 
conception  of  disease  is  based  on  physical  signs. 

We  must  bear  in  mind  that  when  the  body  is 
invaded  by  disease  the  earliest  sign  of  its  presence 
is  invariably  a  subjective  one,  and  that  long  before 
any  physical  sign  is  perceptible  the  patient  himself  is 
conscious  that  something  is  amiss.  To  bring  these 
sensations  to  light  and  to  estimate  their  value  is  one 
of  the  most  difficult  tasks  for  the  physician.  The 
knowledge  can  only  be  acquired  by  careful  noting  of 
the  different  sensations,  and  all  attendant  signs  and 
circumstances.     Then  the  patient  may  have  to  be 


Appendix  II.  211 

watched  for  long  periods  to  see  what  is  the  outcome 
of  his  complaints.  In  this  way  the  physician  may 
in  the  course  of  years  acquire  a  knowledge  which  he 
can  apply  to  other  patients.  Now  as  tlie  out- 
patient department  of  a  hospital  contains  the 
patients  with  disease  in  its  earliest  stage,  how  can 
the  symptoms  ever  be  understood  by  the  young 
inexperienced  physician  ?  The  result  we  see  in  the 
fact  that  no  progress  whatever  is  made  in  this 
subject.  The  difficulties  are  no  doubt  great — the 
observer  is  himself  untrained,  the  number  of  patients 
may  be  too  great,  and  the  patients  are  so  migratory 
that  they  cannot  be  kept  closely  under  observation 
for  a  sufficient  length  of  time. 

The  need  for  studying  the  earliest  stages  of 
disease  is  a  crying  one  and  should  be  realised  b}^  all 
classes.  The  opportunities  of  hospital  and  labora- 
tory workers  are  so  limited  as  to  render  it  impossible 
for  them  to  do  but  a  small  portion  of  this  work,  and 
without  opportunity  all  effort  is  vain.  The  man  who 
has  the  opportunity  is  the  general  practitioner — the 
man  to  whom  the  ailing  individual  first  turns,  and 
the  man  who'  can  watch  the  progress  of  the  disease. 
But  he  is  the  last  individual  from  whom  investigation 
is  expected.  He  has  received  no  instructions  likely 
to  be  of  help  and  his  whole  education  has  impressed 
liim  with  the  idea  that  only  in  hospital  wards  and 
laboratories  can  investigation  be  carried  out. 

One  reason  why  he  has  been  restrained  is  that 
he  has  never  been  taught  how  to  recognise  and 
appreciate  the  symptoms  that  confront  him  in  his 
daily  practice.  The  majority  of  the  patients  who 
consult  hin^  have  no  physical  siorns  to  cnide  him  in 
his  diagnosis — the  symptoms  being  subjective.     The 


278  Appendix  II. 

reason  he  has  never  been  taught  the  meaning  of 
subjective  symptoms  is  very  simple — his  teachers 
are  ignorant  of  them. 

Here  then  is  a  field  for  exploration  unlimited  in 
extent.  The  fact  was  dimly  realised  by  me  some 
thirty  years  ago,  and  as  an  experiment  1  said  to 
m3^self,  "I'll  try  and  find  the  meaning  of  every 
symptom  of  which  the  patient  complains,  and  of 
every  sign  which  I  can  detect."  In  a  few  months' 
time  I  found  such  a  large  number  of  signs  and 
symptoms  to  be  investigated  that  I  had  to  restrict 
myself  to  a  few.  One  of  the  sensations  that  arrested 
my  attention  was  that  of  pain.  This  sensation  is  so 
universal  and  so  informative  that  one  would  expect 
it  to  have  been  the  subject  of  the  prof oundest  study. 
So  far  from  this  being  the  case,  the  elementary 
information  necessary  for  its  consideration  had 
never  even  been  elucidated.  Thus  the  tissues  capable 
of  producing  the  sensation  had  not  even  been 
described,  while  the  mechanism  of  its  production 
had  never  received  any  serious  consideration.  My 
attempts  to  solve  the  question  are  shown  in  this 
book,  but  it  will  be  seen  that  my  knowledge  is  still 
very  imperfect  and  much  requires  to  be  done. 

Other  signs  arrested  my  attention,  such  as  the 
irregular  action  of  the  heart.  The  result  of  that 
investigation  has  thrown  a  light  upon  the  heart's 
varied  action  in  health  and  disease,  as  to  give  a  new 
conception  of  heart  failure  and  its  treatment. 
Others  indeed  had  studied  this  subject,  and  added 
greatly  to  our  knowledge,  but  what  nearl}^  all 
contented  themselves  with  was  the  elucidation  of 
how  a  given  irregularit}^  was  produced,  whereas  I 
concerned  myself  with  the  question  of  what  happened 


Appendix  II.  279 

to  people  who  showed  dA\y  form  of  irregularity. 
Xow  the  last  question  is  one  of  prime  necessity  to 
the  physician,  yet  it  is  one  which  the  profession  up 
till  now  has  never  really  appreciated.  What  use  is 
it  to  tell  a  man  that  he  has  got  a  murmur  or  an 
irregularity  or  any  other  abnormal  or  supposed 
abnormal  sign,  unless  you  can  tell  him  at  the  same 
time,  with  a  knowledge  drawn  from  experience, 
what  is  to  happen  if  the  condition  is  untreated,  or 
if  it  is  susceptible  to  treatment,  or  if  it  needs  treat- 
ment at  all  ? 

If  an3^one  wishes  to  realise  how  unexplored  tliis 
essential  field  of  knowledge  is,  let  him  take  any 
striking  or  abnormal  sign  which  the  practitioner 
recognises,  let  him  turn  to  a  library  of  medical 
treatises  in  any  language,  and  seek  to  get  the 
knowledge  essential  to  him  as  a  practitioner,  and 
he  will  discover  that  what  he  wants  to  know  is  not 
there,  or  the  description  is  so  vague  as  to  be  useless 
where  it  is  not  misleading.  Sometimes  he  may  find 
a  sort  of  reply,  but  if  he  inquires  into  the  reasons 
the  author  has  for  his  opinion  he  will  only  get  for 
proof  an  "  impression." 

If  the  enquiring  practitioner  should  wish  for  a 
line  of  treatment  he  will  usually  be  overwhelmed 
with  the  multitude  of  drugs  and  methods  ;  but  if 
he  again  seeks  to  inquire  into  the  reasons  for  the 
recommendation  of  any  one  treatment  he  will 
discover  no  detailed  and  accurate  account  anywhere 
— only  an  "  impression."  I  question  if  there  is  a 
single  drug  in  the  whole  pharmacopoeia  whose 
effect  on  the  human  system  in  health  and  disease 
has  ever  been  carefully  studied.  So  far  as  I  have 
gone  into  the  question  tlio  vast   majority  of  these 


280  Appendix  II. 

drugs  are  without  value,  while  the  really  useful 
drugs  have  never  been  so  studied  as  to  enable  them 
to  be  employed  with  the  greatest  benefit.  Nor  must 
we  look  to  the  pharmacological  laboratory  for  the 
solving  of  this  question,  for  in  my  researches,  small 
as  they  are,  I  have  found  that  disease  modifies  the 
action  of  remedies  in  a  most  marvellous  manner,  a 
fact  which  any  one  would  surmise,  but  one  which  is 
ignored  in  the  use  of  remedies. 

Another  great  field  has  yet  to  be  explored. 
We  all  recognise  the  great  advance  that  has  been 
made  in  the  bacteriological  study  of  disease,  and 
we  all  realise  that  a  great  many  obscure  diseases 
are  probably  microbic  in  origin,  and  that  the 
bacteriological  investigation  of  disease  is  yet  in  its 
infancy.  The  advance  in  this  field  will  be  greatly 
imperilled  unless  it  goes  hand  in  hand  with  clinical 
observation.  Not  only  must  the  germ  producing  the 
disease  be  recognised  but  the  symptoms  it  provokes 
must  be  ascertained.  If  this  is  not  done  the  results 
of  bacteriology  will  be  restricted  in  two  waj^s.  It 
is  manifest  that  it  is  impossible  for  the  great  majorit}^ 
of  patients  ever  to  have  the  benefit  of  a  bacterio- 
logical examination.  These  patients  are  mostly 
under  the  care  of  general  practitioners,  and  the 
opportunity  for  such  examination  is  rare.  It  is, 
however,  certain  that  the  symptoms  provoked  bj^ 
each  microbe  differ,  and  the  physician,  by  noting 
the  sj'mptoms  in  cases  verified  by  bacteriological 
examination,  will  by  and  bye  be  able  to  recognise 
the  specific  disease  from  clinical  signs.  We  already 
recognise  a  great  man}^  of  these  germs  produced 
diseases,  as  scarlet  fever,  measles,  influenza,  typhoid 
fever.      The   characteristic   reaction   to   the   toxins 


Appe7idix  II.  281 

produced  by  a  microbe  is  well  illustrated  by  ^Marris's 
discover}^  in  typhoid  fever,  and  he  has  shown  that 
the  reaction  of  the  toxin  in  the  heart  modifies  its 
action  in  a  striking  manner,  rendering  it  less  liable 
to  stimulation.  Thus  effort,  or  the  administration 
of  atropin,  which  in  normal  hearts  increases  the  rate 
of  the  heart,  does  not  increase  the  rate,  or  only  very 
slightly,  in  typhoid  fever.  So  far  tj^phoid  fever  is  the 
only  infectious  state  in  which  this  peculiarity  is 
present,  and  in  case  of  doubt,  by  gi^^ng  an  injection 
of  atropin  and  noting  its  effect  on  the  heart,  the 
diagnosis  can  be  made.  We  all  know  the  difficulty 
in  diagnosing  such  a  disease  in  its  early  stage,  and 
the  bacteriological  test  is  not  alwa3^s  available ;  and 
when  available  it  is  late  before  it  is  effective,  and 
needs  special  apparatus  and  specialh^  trained  men 
for  its  accomplishment.  Here  any  practitioner  can 
apply  the  test  and  get  the  result  in  half  an  hour. 

Another  most  valuable  field  remains  to  be 
explored.  A  large  number  of  people  suffer  from 
infirmities  which  limit  their  activities,  yet  they  may 
live  many  years.  Many  are  under  present  conditions 
unable  to  earn  a  livelihood,  or  in  their  attempts  to 
do  so  injure  themselves.  The  suitable  employment 
of  people  with  chronic  diseases  and  of  the  manage- 
ment of  their  daily  life  has  never  been  studied  with 
that  care  that  the  subject  needs.  All  general 
practitioners  have  this  subject  forced  upon  them, 
and  some  have  acquired  in  the  course  of  many  years' 
experience  of  success  and  failure,  a  dim  perception 
of  its  handling.  But  no  accurate  knowledge  is  to 
be  found  anywhere,  and  here  again  the  man  with  the 
opportunity  is  the  only  man  that  can  undertake  its 
study. 


282  Appendix  II. 

We  see  therefore  that  these  great  fields  of 
research  need  attention — the  early  stage  of  disease, 
the  progress  of  disease,  the  action  of  remedies,  and 
the  management  of  the  lives  of  individuals  with 
impaired  health.  There  are  many  fields  unharvested 
and  waiting  only  for  the  reaper.  The  question  may 
be  asked,  how  is  one  to  set  about  this  work  ?  As  I 
have  said,  it  is  of  no  use  for  a  young  man,  just 
qualified,  to  undertake  research  work.  These 
scholarships  given  to  encourage  research  usually 
end  in  a  waste  of  time.  If  a  young  man  wishes  to 
work  in  a  laboratory  he  may  do  so  in  order  to  acquire 
a  knowledge  of  methods,  but  he  will  never  do  much 
to  advance  medical  science  until  he  has  acquired 
experience.  It  would  be  better  if  research  in 
medicine  were  delayed  until  the  investigator  had 
realised  exactly  where  knowledge  was  deficient  from 
personal  experience.  Let  him  devote  some  years  to 
the  study  of  disease  as  manifested  in  patients ;  let 
him  analyse  each  symptom,  subjective  and  objective;, 
let  him  try  to  understand  the  mechanism  by  which 
each  sign  and  symptom  is  produced ;  let  him  under- 
stand its  bearing  on  the  efficiency  of  the  organism, 
taking  into  consideration  all  associated  phenomena, 
and  how  it  becomes  modified  as  the  disease  pursues 
its  course.  Simple  as  these  suggestions  are,  if  they 
are  followed,  I  have  no  doubt  but  that  the  lines  to  be 
pursued  will  become  evident  to  anyone  who  seriously 
undertakes  to  investigate  disease. 


INDE 


INDEX. 


ABDOMINAL 

respiration,  206. 

tumour,  55,  72,  177,  202. 

wall,  10,  33,  52,  71,  267. 

wall,  increased  sensibility,  63,   199. 

See  "  Hyperalgesia. 

ADAMS-STOKES 

syndrome,  257.  ' 

ADHESIONS 

after  operation,  201. 
peritoneal,  174,  198. 

parietal,  200. 

visceral   202. 


ADHESIVE    MEDIASTINITIS 

case,  242. 

AEEATION 

of  blood,  211. 

tissues  in  heart  disease,  208. 


Index.  285 


AFFECTIONS 
of  anus,  174. 
bladder,  189. 

cerebro-spinal  nerves,  110. 
circulatory  system,  219. 
digestive  organs,  115. 
female  pelvic  organs,  193. 
intestines,  167. 
kidney,   178. 
liver,  etc.,  156. 
lungs,  204. 

pelvis  of  kidney,  180. 
perineum,  174. 
pleura,  214. 
stomach,  132. 
ureter,  180. 
urinary  system,  178. 

AIR-HUNGER,  205. 


AIR-SUCTION 

in  stomach,  142. 

ALBUMINURIA,  178,  179,  259. 


ALCOHOLIC 

gastric  catarrh,  123. 
morning  sickness,  140. 


AMPHIOXUS,  94. 

ANGINA  PECTORIS,  47,  56,  74,  80,  95  (fig.),  124,  231,  236, 
238  (figs.),  261. 
cause,  248. 

ANOREXIA,  120. 

ANUS 

affections  of,  174. 
nerve-supply,  116. 


286  Index. 

AOKTIC 

dilatation,  case,  240. 
disease,  facial  aspect,  102. 

APOPLEXY 

pvilmonary,  expectoration  in,  209. 

APPEARANCE    OF    PATIENTS.  99. 
APPENDICITIS,  43,  73,  74,  81,  171. 

APPETITE,  119. 
perverted,  121. 

AREAS 

of  cutaneous  hyperalgesia,  65. 

in  angina  pectoris,  95,  236. 
dilatation  of  heart  and 

liver,  233. 
diaphragmatic  pleurisy,  216. 
gall-stone  colic,  157,  200. 
peritonitis,  198. 
renal  colic,  181,  188. 
eruption  in  herpes  zoster,  98. 
muscular  hyperalgesia,  68. 
pain  in  angina  pectoris,  95. 
bowels,  117,  169. 
diaphragmatic  pleurisy,  216. 
digestive  tube,  117 
gastric  ulcer,  150,  152,  154. 
intestines,  117,  169. 
oesophagus,  117. 
pleurisy,  diaphragmatic,  216. 
renal  calculus,  187. 
stomach,  117. 
over  vertebral  spines,  69. 

ARTERIOSCLEROSIS,  244. 


ASTHMA,  80,  207. 
cardiac,  80,  229. 


Index.  28" 


ATHEROMA 

of  coronary  arteries,  243,  245,  247,  248. 

ATONIC    DYSPEPSIA,    145. 

AUTONOMIC 

nerves,  diagram,  27. 
nervous  system,  25. 


B 


BACKACHE,  178. 

BILE-DUCTS,  156. 
in  fseces,  176. 

BISMUTH 

in  intestines,  168. 

BLADDER 

affections  of,   189. 
calculus  in,  76,  185,  188. 
development,  189. 
functional  symptoms,  191. 
irritation  of,  190. 
nerve-supply,  189. 
over-distension,  189. 
pain  iui  118. 
secretion,   191. 
structural  symptoms,  192. 

BLISTER 

on  epigastrium,  153,  268. 

BLOOD 

aeration  of,  211. 
in  f feces,   176. 

heart  disease,  208. 

BODY    WALL 

sensitive  tissues,  33. 

See  "  Abdominal." 


288  Index. 

BOULIMIA,  121. 
BOWELS.     See  "  Intestines.' 

BRAIN    MEMBRANES 

sensitiveness,  110. 

BREATHERS 

mouth-,  127. 

BREATHLESSNESS,  227. 

BRONCHITIS 

expectoration  in,  213. 


CALCULUS 

in  bladder,  76,  184,  188. 
renal.     See  "  Colic,  Renal." 
ureteral,  site  of,  182,  184. 

CAMPBELL 

on  herpes  zoster,  60,  67,  128. 

CANCER 

of  liver,  165. 

stomach,  70,  143. 

CARDIAC 

asthma,  80,  229. 

condition,  facial  aspect,   102. 

murmur,  108. 

reflexes,  81. 

valvular  imperfection,  222,  237,  252. 

CASE    REPORTED 

of  adhesive  mediastinitis,  242. 

angina  pectoris,  237,  239,  242,  244,  245,  247,  248,  253. 
aortic  dilatation,  240. 
appendicitis,  42,  74. 
atheroma,  243,  245,  247,  248. 


Index.  289 

CASE    REPORTED— roniwwfrf. 

of  blood-pressure,  high,  240,  2-45. 

calculus,  renal,  44,  76,  184,  186,  188. 

cardiac  rupture,  248. 

cardiac  valvular  disease,  237,  253. 

cholecystotomy  (Lennauder),  51. 

colic,  gall-stone,  90. 

renal.     See  "  Calculus." 

dilatation  of  aorta,  239. 

enlargement  of  heart,  242,  245. 

fibrous  myocarditis,  242. 

gall-stone  colic,  90. 

gastric  ulcer,  91,  148,  149,  151,  153,  155,  253. 

high  blood  pressure,  239. 

Lennander's  cholecystotomy,  51. 

mediastinitis,  adhesive,  242. 

nodal,  rhythm  of  heart,  244. 

operation  for  umbilical  fistula  without  anajsthetic,  39. 

perforation  of  gastric  ulcer,  148,   149,  151,  199. 

peritonitis,  199. 

pyloric  stenosis,  202. 

renal  calculus. 

colic.     See  "  Calculus." 
rupture  of  heart,  248. 
stomach  affections,  series,  136. 
ulcer,  gastric.     See  "  Gastric." 


CEREBRO-SPINAL 

nerves,  affections  of,   109. 

pain  in,  28. 
nervous  system,  25 


CHEYNE-STOKES 

respiration,   228 


CHLOROFORM 

effects  of,  in  joint  disease.   111. 
parturition,   175. 
on  contracted  muscle,  74. 

CHLOROSIS 

facial  usp(;ct,    1()L'. 


290  Index. 

CHOLANGITIS,  162. 

CHOLECYSTOTOMY 

pain  in,  51. 

CHOLERA 

stools,  177. 

CIRCULATION 

affections  of,  219. 
condition  of,  106. 

CIRRHOSIS 

of  liver,  165. 

atrophic,  166. 

COLD 

in  stomach,  sensation  of,  9. 

COLIC 

appendicular.  172. 

gall-stone,  63,  90,   134,   137,  157. 

intestinal,  39. 

-like  pains,  118. 

renal,  44,  46,  58,  74,  75,  92,  119,  180,  183,  185,  187,  188. 

COMPLEXION,  102,  164,  208. 

CONDITION 

of  organs,  106. 

patient,  general,  105. 

CONSCIOUSNESS 

of  heart's  action,  225, 

CONSTRICTION 

of  stomach,  145. 

CONTRACTION 

of  heart- muscle,  249. 
muscles,  72,  88,  92. 
non-striped  muscle,  181,  262,  263. 
stomach,  hourglass,  145. 
uterus,  194. 


Index.  291 

COOK 

on  swallowing  fluids,  129. 

CORD 

spinal,  irritable  foci  in,  89,  92. 

COUGH,  209. 

in  extra-systole  of  heart,  210. 

CRAMP 

of  muscles,  112. 
stomach,  137,  160. 

CREMASTER 

muscle,  181. 

CREPITATIONS 

at  base  of  lung,  229. 

CURES 

value  of,  267. 

CUSHNY 

experiments  on  mammalian  heart,  11. 

CUTANEOUS 

hyperalgesia,  64,  87  (fig.),  90. 
areas,  67. 

(figs.)  95,  158,  183,  187,  216,  231,  238. 
reflex,  86,   139. 
segments,  67. 


DEEP    PAIN,  58. 

DEVELOPMENT 

of  appendix,   173 
l)ladder,  188. 
liver,  etc.,  156. 
nervous  system,   19,  96. 


292  Index. 

DIAGNOSIS 

differential,  113. 

of  intestinal  affections,  167. 

stomach  affections,  145. 
treatment  as  a  factor  in,  265. 

DIAPHRAGMATIC   PLEURISY,    216    (tig.),    217. 

DIARRHOEA 

facial  aspect,   103. 

DIARRHCEIC 

stools,  177. 

DIETS,  146. 

DIGESTIVE 

organs,  affections  of,  115. 
system,  inquiry  into,  106. 
tract,    areas  of  pain,  117  (fig.). 

functional  symptoms,  176. 

nerve-supply,   115. 

sensory  symptoms,   116. 

DILATATION 

of  aorta,  case,  239. 

heart  and  liver,  233,  234  (fig.). 
stomach,  107,  143,  147. 

DIRECT    PAIN,    84. 

DISEASE,  17. 

Graves',  facial  aspect,  103. 

of  organs.     See  under  Organs  affected. 

DISTRIBUTION 

of   herpes  zoster,  97  (fig.),  98. 
thoracic  nerves,  94  (fig.),  96. 

DUCTS 

bile-,  156 


Index  293 


DUSKI>^ESS 

of  skill,  102,  211. 

DYSPEPSIA,  159. 
atonic,  145. 

DYSPXCEA,  79,  207. 


EAR 

herpes  zoster  on,   128. 

EMPHYSEMA 
liver  ill,  166. 

ENDOMETRITIS,  91,  92. 

ENEMA 

pain  of,  39. 

ENGELMANN 

experiment  on  frog's  heart,   11. 

EPIGASTRIC 

blister,  153,  268. 
pain,   136. 
reflex,   139. 
symptoms.   135. 

EPILEPSY,  257. 

EUSTACHIAN    TUBE 

sensation  in,   126. 

EXAMINATION 
of  patient,  99. 

EXHAUSTION 

effect  on  symptoms,  255. 
of  lieart,  220,  225,  228,  262. 


294  Index, 

EXPECTORATION,  212. 

EXTRA-PERITONEAL    TISSUE 

sensitiveness  of,  34,  66. 

EXTRA-SYSTOLE 

of  heart,    136,  224,  227,  233. 
cough  in,  210. 


FACIAL    ASPECT 

in.  liver  aSections,  164. 
of  patients,  99. 

FiECES 

examination  of,   176. 
•   impacted,  171. 

FAUCES 

affections  of,  123. 
in  swallowing,  128. 
nerve  supplj^,  116. 

FEBRILE  STATES 
tongue  in,  127. 

FEMALE 

pelvic  organs,  193. 

FEVER 

in  gall-stone  disease,  162. 

FISSURE 

of  arus,  175. 

FLATULENCE,  141. 

FOCI 

in  spinal  cord,  irritable,  89,  92,   133. 


Index,  295 


FOOD 

pain  after,  134,   138. 
retention  in  stomach,  144. 

FUNCTIONAL    SYMPTOMS,    20. 
of  bladder,   191. 

digestive  tube,   176. 

gall-stone  disease,   161. 

kidney,  178. 

liver,  164. 

respiratory  affections,  211. 

stomach,   143. 

FUNCTIONS 

of  stomach,  132. 
heart  muscle,  249. 

FURRED  TONGUE,  126. 


GALL-BLADDER,  156. 
sensation  in,  50. 

GALL-STONE 

colic,  63,  90,  134,  137,   157 
pain,  47,  48,  101,  119,   157. 
in  shoulder,  159. 

GALL-STONE    DISEASE,    147. 
facial  aspect,   102. 
fever  in,  162. 
functional  symptoms,   161. 
gastric  symptoms,  137,  159. 
reflex  symptoms,   157,  267. 
structural  symptoms,   161. 
taken  for  pleurisy,   160. 

GASTRIC 

catarrh  of  alcoholics,   123. 

symptoms  in  gall-stone  disease,    137     159. 


296  Index, 

Gk^T^lC—contwiml 

ulcer,  73,  75,  91,  133,  145,  253,  267. 
perforation,  148,  149,  151,  199. 
paiii  ill,  5,  91,  138,  147. 

site  of  pain,  147,  150  (fig,),  152  (fig.),  154  (fig.),  199, 
vomitinjz  in,   140. 

GASTKITIS,   133,  140,  160. 

GENEEAL    CONDITION 
of  patient,  104. 

GENITO-CRURAL 

nerve,   184. 

GEOPHAGY,  121 
GOOSE-SKIN,  82. 

GRAVES'    DISEASE 

facial  aspect,  103. 


H 

HAEMORRHOIDS,  92,  174. 

HALDANE 

on  air-hunger,  205. 

respiratory  trouble,  208. 

HALLER 

on  insensitiveness  of  viscera,  33. 

HARVEY 

on  insensitiveness  of  heart,  33. 

HAST 

on  Lennander's  observations,  50. 

HEAD 

on  cutaneous  hyperalgesia,  64. 
herpes  zoster,  60,  67,   128. 
muscle  pain,  68. 


Index.  297 

HEADACHE,  109. 


HEALTH 

definition,  etc.,   17. 


HEART 

action,  consciousness  of,  225. 
affections,    219. 

area  of  pain,  69  (fig.), 
-block,  136,  257. 
dilatation,  233,  234  (fig.), 
-disease,  respiration  in,  208. 
enlargement,  242. 
exhaustion,  221,  225,  228,  262. 
extra-systole,   136,  210,  224,  227,  233. 
failure,  220,  265. 

facial  aspect,  102. 

enlartied  liver,  163,   165. 
frog's,  Engelmann  on,   11. 
inquiry  into  condition,  106. 
irregularities,  11,  108,  257. 
mammalian,  Cushny  on,  11. 
-muscle,  248. 
nodal  rhythm,   163. 
reflexes,  81. 
rupture,  248. 
spasm,  249. 
treatment,  265. 
valvulaf  imperfection,  222,  237,  253. 


HEART-BURN,  129,  135,   141. 
HEPATOPTOSIS,  166. 


HERNIA 

pain  in  radical  cure,  35. 
strangulated,   170. 


HERPES    ZOSTER.  60,  67,  97  (fig.).  98. 
iu  tonsilitis.   128. 


298  Index. 

HIRST 

on  swallowino-  fluids,  129. 


HILTON 

on  joint  affections,  111 


HIP-JOINT    DISEASE 
pain  in,  111 


HUNGER,  122. 
Air-,  205. 


HYDATIDS 

of  liver,  165. 


HYPERALGESIA,  63. 

cutaneous,  64,  87  (fig.),  89. 
areas  of.  67. 

(figs.)  95,   158,  183,  187,  216,  234,  238. 
in  affections  of  respiration,  231. 

stomach,  138,  200. 
angma  pectoris,  236,  238  (figs.), 
obstruction  of  bowel,  170. 
peritonitis,   199. 
muscular,  34,  65,  87  (fig.),  90. 
areas  of,  68. 
effect  of  exercise,  66. 
of  extra-peritoneal  tissue,  66. 
mammae,  66. 
testicle,  66. 


HYPERCHLORYDRIA,  138,  141, 


HYPOTHESES 

law  of  parsimony  of,   12. 
value  of,  6. 


HYSTERIA,  255. 


Index,  299 

I 

ICE 

pain  of  swallowing,  136. 

INDIGESTION,  134. 

INFANTILE    DIARRHCEA 
stools,  177. 

INSEN8ITIVENESS 

of  viscera,  33,   193,   198,  2U. 

See  "  Sensibility  or  Sensitiveness." 

INSURANCE 

examination  for,  259. 

INTERCOSTAL    MUSCLES,    215,    243. 

INTESTINES 

affections  of,  167. 
obstruction,  169,  186. 
pain  in,  117  (figr.),  118. 
peristalsis  of,  40,  118,  168,  169. 

IRREGULARITIES 

of  heart,  11,  108,  257. 

IRRITABLE    FOCI 

in  spinal  cord,  89,  92,  133. 


JAUNDICE,  103,  161,  164. 

JOINT 

inflamed,  71. 

knee-.   111. 

nerve-supplv,   112. 

shoulder-,  71,   111. 

stiffness,   112. 

under  chloroform.   111. 


300  Index. 

K 

KIDNEY 

affections  of,  178. 
-disease,  13,  22. 
movable,  55,  179. 
-pelvis  and  ureter,  180. 


KNEE 

-joint,  pain  from.  111. 
in  hip-joint  disease,  111. 


LABOUR 

uterus  during,  194. 


LANGLEY 

on  dilatation  of  pupil,  83. 

's  diagram  of  autonomic  nerves,  27,   115. 


LARYNGEAL  NERVE,  209. 
LARYNX,  209. 


LENNANDER'S    OBSERVATIONS 

on  pain,  49. 


LIVER,  156. 

area  of  pain  in  affections  of,  69  (fig.), 
enlarged,   2,  161,  164,  165. 

in  heart  failure,  163,  165,  233,  23-1   (fia.l 
facial  aspect  in  affections  of,   102,  164. 
symptoms,  functional,  164. 
reflex,  163. 
structural,  165. 


Index.  30 1 

LOCALISATION 
of  lesion,  93. 

pain,  28,  41,  55,  59,  88,  101,  136,  US,  168,  170. 
renal  calculus,   183. 

LUMBAGO,  92,  113. 

LUNG 

affection  of,  204. 
condition,  inquiry  into,   106. 
crepitations  at  base,  229. 
stasis  or  oedema,  230. 


M 


MALARIAL    CACHEXIA 

facial  aspect,  102. 

MALIGNANT    DISEASE 

facial  aspect,   102. 

of  stomach,  70,  142,   147,  252. 

MALINGERING,  255. 

MAMMiE 

hyperalgesia  of,  66. 

MAYLARD 

on  peritoneal  adhesions,  201. 

McBURNEY'S 

point,  68. 

MEDIASTINITIS 
adhesive,  242. 

MELTZER 

on   Lcuuiinder's  observations,  50. 

MEMBRANES 

oi  brain,  scnsitivciu'ss  of,   110. 


302  Index. 

MEEYCISM,  141. 

MICTURITION,  106,  175,  179,  190,  191. 

MISCARRIAGE,  195. 

MORNING    SICKNESS 
alcoholic,  140. 

MOTOR 

nerves,  stimulation  of,  72,  92. 
symptoms,  110. 

MOUTH 

afEections  of,  123. 
-breathers,  127. 
nerve-supply,  116. 

MUCUS 

in  fseces,  176. 

MUSCLES 

abdominal,  bard  contracted,  10,  71. 

simulating  tumour,  72,  202. 
contraction  of,  73,  88,  92. 
cremaster,  181. 

effects  of  stimulation  of  motor  nerves,  72. 
heart-,  249. 

in  joint  affections.  111. 
mtercostal,  215,  243. 
levator  palati,  127. 
non-striped,  181,  262,  263. 
of  respiration,  206. 
rectus,  135,  139. 

MUSCULAR 

cramp,  112. 

hyperalgesia,  34,  65,  87  (fig.),  90. 

areas  of,  68. 

effect  of  exercise,  66. 
layer  of  body  wall,  sensitiveness  of,  34,  51,  199. 
rheumatism,"^  113,  215,  243. 


Index.  .'JO.'i 

N 


NAUHEIM    TREATMENT,  265. 


NAUSEA,  122. 


NERVES 

cerebro-spinal,  affections  of,   109. 

pain  in,  28. 

to  digestive  tract,  115. 
chorda  tvmpani,  116. 
cranial,  fifth,  116,  123. 
genito-crural,  184. 
glosso-pharyngeal,  116. 
lar\nigeal,  209. 

motor,  stimulation  of,  72,  92. 
of  taste,  116. 
olfactory,  116. 

phrenic,  48,  157,  216  (fig.),  218. 
sensory,  4. 

stimulation  of,  72,  92,  268. 
sympathetic  to  stomach,  134. 
thoracic,  94  (fig.),  96,   135. 
vagus,  134,  157,  246. 


NERVE-SUPPLY 
of  anus,  174. 
bladder,  189. 
digestive  tract,  115. 
gall-bladder,  156. 
joints,  etc.,  112. 
liver,  etc.,  156. 
ovaries,  195. 
perineum,  175. 
pleura,  215, 

respiratory  muscles,  206. 
stomach,  134. 
ureter,  180. 


304  Index. 

NERVOUS    SYSTEM 

autonomic,  25,  27  (fig.)- 
cerebro-spiiial,  25. 
constitution,  25. 
development,   19. 

NEURALGIA 

trigeminal,  124, 

NEURASTHENIA.     See  '^  Neurotic." 
NEURITIS,  48,  114,  159. 

NEUROTIC 

temperament,   etc.,    104,    142,    180,    226,    252,   253. 

NODAL    RHYTHM 

of  heart,  163. 

NOMENCLATURE,  13. 


OBSERVATION 
accuracy  of,  2. 
method  of.  6. 

OBSTRUCTION 

of  intestines,  169,   186. 
pyloric,   140,  144,  202. 

(EDEMA 

pulmonary,  229. 


(ESOPHAGEAL    PAIN,  61,  116,  11{<. 
area  of,  117. 

OESOPHAGUS,  128. 
nerve-supply,  116. 
stricture  of,  130. 


Index.  305 


OPERATION 

adhesions  after,  201. 

ou  ovary,   107. 

for  appendicitis,  paiji  in,  4.3. 

gall-stone,  pain  in,  50. 

umbilical  fistula,  pain  in,  40. 

ORAL    ORIFICE 

nerve-supply,  116. 

ORGANIC    REFLEXES,  78,  87  (fig.),  88,  247. 

ORGANS 

digestive,  affections  of,  115. 
female  pelvic,  affections  of,  193. 
review  of,  105. 

ORTHOPNCEA,  227. 

OVARIES,  195. 

OVARIAN    TUMOURS,  203. 

OVARY 

operation  on,  107. 


PAIN 

after  food,  133,  137. 

colic-like,  118. 
deep,  58. 
definition  of,  24. 
differential  diagnosis,  113. 
direct,  84. 
in  abdominal  tumour,  55. 

angina  pectoris,  47,  56,  95,  236,  238. 

appendicitis,  43. 

cerebro-spinal  nerves,  28. 

digestive  tract,  117  (fig.). 

gall-stone  disease,  47,  48,  157. 


306  Index. 

PAIN — continued. 

ill  gastric  ulcer,  5,  147.     See  "  Gastric  Ulcer." 

hip-joint  disease,   111. 

knee-joint,  111. 

movable  kidney,  55. 

muscles,  68. 

CESophagus,  61,  116,  118,  128. 

ovarian  trouble,  195. 

peristalsis  of  intestine,  39,  118,   169. 

pleurisy,  215,  216  (fig.). 

pneumonia,  217. 

radical  cure  of  hernia,  35. 

renal  colic,  44,  46,  58.     Sec  "  Colic,  Kenal." 

shoulder,  101,  111,  159,  217. 

stomach,  69,  118,  135,  138,  140. 

testicle,  36. 

tunica  vaginalis,  37. 

ureter,  182,  184. 

uterine  labour,  194. 

vagma,  196. 

vertebral  spines,  69  (fig.). 

visceral  disease,  41,  114. 
localisation  of,  29,  41,  55,  59,  85,  101,  150  (fig.),  168. 
radiation  of,  29,  46. 
referred,  46,  84. 
sensitiveness  of  tissues  to,  26. 
somatic,  8,  46. 
splanchnic,  8,  46,  54. 
visceral,  4,  8,  26,  32,  46. 

artificial  production,  38. 
mechanism,  41,  85,  87  (fig.). 
radiation,  47. 


PALATAL    MUSCLES,    127. 


PALLOR 

of  face,  102. 


PALPITATION,  226. 

PARSIMONY    OF    HYPOTHESES 
law  of,   12. 


Index.  :i07 


PAKTURITION 

perineal  reflex,  175. 

PATIENT 

appearance,  99. 
examination,  99. 
facial  aspect,   102. 
general  condition,  104. 
sensations,  100,  204. 

PELVIC    ORGANS 
female,   193. 

PELVIS    OF    KIDNEY 

affections  of,  180. 

PERFORATION 

of  stomach,  148,  149,  150,  199. 

PERINEUM,  175. 

PERISTALSIS 

of  intestine,  39,  118,  168,  169. 
oesophagus,  130. 

PERITONEAL    ADHESIONS,  174,  198. 
parietal^  200. 
visceral,  202. 

PERITONEUM 

sensitiveness  of,  35,  50,  198. 
sensitive  layer  outside,  34,  66. 

PERITONITIS,  35,  75,  171,   198. 

PERITYPHLITIS,  73. 

PERNICIOUS    AN^.MIA 
facial  aspect,   102. 

PHRENIC    NERVE,  48,  157,  216,  218. 


308  Index. 

PILES,  92,  174. 
PILO-MOTOR    REFLEX,    82. 

PLEURA 

aflections  of,  204,  214. 

PLEURISY,  215. 

and  gall-stone  disease,   160. 
diaphragmatic,  area  of  pain,  216  (fig.). 

PLEURODYNIA,  113. 

PNEUMONIA 

expectoration,  213. 
facial  aspect,  103. 
pain,  217. 
stools,  177. 

PREGNANCY 

vomiting  in,  196. 

PREGNANT    UTERUS,    194. 
PRIMITIVE    VERTEBRATE,    93. 
PROGNOSIS,  258. 

PULMONARY 

apoplexy,  expectoration,  213. 
condition,  facial  aspect,   102,  211. 
stasis,  229. 

PULSE 

irregular,  224. 

PYLORIC    STENOSIS,    140,  144,  202. 
PYROSIS,    140. 


Index.  309 

R 

KADIATION 

of  pain,  29,  46. 

EAMSTROM 

on  histology  of  abdominal  wall,  35,  139,  200. 

RECTUM 

area  of  pain  in  affections  of,  69  (fig.), 
ulceration  of,  175. 

RECTUS    MUSCLE,  135,  139. 

REFERRED    PAIN,    46,    84. 

REFLEX 

cardiac,  81. 

exaggerated,  92. 

organic,  78,  87  (fig.),  88,  247. 

perineal,  175. 

pilo-niotor,  82. 

purpose  of,  19. 

secretory,  80. 

skin  or  superficial,  85,   139. 

symptoms,  17,  84. 

vaso-motor,  82. 

viscero-motor,  10,  42,  71,  87  (fig.),  88,  139,  230,  24.3- 

viscero-sensory,  42,  230,  233,  236. 

REFLEXES 

in  angina  pectoris,  232. 
gall-.stone  disease,   157. 
kidney  affections,  178. 
liver  affections,  163. 
parturition,   175. 
respiratory  affections,  209. 
stomach  affections,   137. 
visceral  disease,  49. 

REGURGITATION 

from  stomach,   135,   138,   141. 


310  Inde^. 

EEMOTE    EFFECTS 
of  lesion,  254. 

RENAL 

calculus 
colic 

See  "  Colic,  Renal." 

RESPIRATION,  206. 

Cheyne-Stokes,  228. 
with  failing  heart,  229. 

RETENTION 

of  food  in  stomach,  144. 
urine,  189. 

RHEUMATISM 

muscular,  113,  215,  243. 

ROSS 

on  visceral  pain,  8,  46. 

RUPTURE 

of  heart,  248. 


SALIVA 

flow  in  angina  pectoris,  247. 

SCHLESINGER 

on  swallowing  fluids,  129. 

SCYBALiE 

in  intestine,  171. 

SECRETIONS 

of  bladder,  191. 
stomach,  143. 

SECRETORY    REFLEXES,  80. 


Index.  3 

SEGMENTS 

of  cutaneous  surface,  67. 

SENSATION 

of  cold  ill  stomach,  9. 

SENSATIONS 

in  affections  of  lungs  and  pleura,  204. 

viscera,  9. 
of  patient,  100. 

SENSIBILITY    OR    SENSITIVENESS 

of  brain  membranes,  110. 

extra-peritoneal  connective  tissue,  34,  66. 
female  pelvic  organs,  193. 
membranes  of  brain,  110. 
synovial,  112. 
muscular  layer  of  body-wall,  34,  63. 
peritoneum,  35,  198. 
pleura,  214. 

synovial  membrane,  112. 
tissues,  26,  33,  63. 

SENSORY 
nerves,  2. 
symptoms,  110. 

in  digestive  tract,  116. 

SHERRINGTON,    PROFESSOR 

on  areas  of  cutaneous  nerve  supply,  67. 
muscular  response  to  stimulation,  72. 
radiation  of  pain,  29. 
stimulation  of  nerves,  76,  83,  268. 
visceral  nerves,  10. 

SHOULDER-JOINT,  71.  113. 

pain,  101,  159,  216  (fig.),  217. 

SICKNESS 

morning,  alcoholic,   140. 

SITE    OF    PAIN.     See  "  Area,"  and  "  Localisation." 


312  Index, 

SKIN 

duskiuess,  102,  211. 
goose-,  82. 
-reflex,  85,  139. 
sensibility,  in,  33. 

See  "  Cutaneous." 

SNEEZING,  210. 
SOMATIC    PAIN,    8,    46. 

SPASM 

in  swallowing,  130. 
of  the  heart,  249. 

SPINAL 

column  disease,  70. 

tenderness,  68. 
cord,  irritable  foci,  89,  92. 

SPLANCHNIC    PAIN,  8,  46,  54. 

STASIS 

pulmonary,  229. 

STENOSIS 

of  cardiac  valves,  237. 
pyloric,  140,  141,  202. 

STIFF-NECK,    113. 

STIFFNESS 

in  joints,   112. 

STIMULI 

summation  of,  as  cause  of  angina  pectoris,   248. 

STOMACH 

aiTectious  of,   131. 

areas  of  pain,  69  (fig.),   117  (fig.),   118,   136. 
cold  in,  sensation,  9. 
constriction  of,   145. 


Index.  313 


STOMACH— con^inwerf. 

contents  in  oesophagus,   128,   135,   138,   141. 

cramp,  13-1,  160. 

derangement,  22,   132. 

diagnosis,  145. 

dilatation  of,  107,   143,   147. 

functions,  132. 

functional  symptoms,  143. 

hyperalgesia  from,   138. 

malignant  disease,  70,   143,   147,  252. 

nerve  suppW,  134. 

pain,  areas, "69  (fig.),  117  (fig.),  118,  136. 

pain  with  gall-stone  colic,  90. 

perforation,  148,  149,  151. 

peristalsis,  135,   138,  141. 

pyloric  stenosis,   141,  144,  202. 

regurgitation  from,   129,   135,   138,  141. 

retention  of  food,  144. 

secretion,  143. 

stenosis,  140,   144,  202. 

treatment,  146,  266. 

tumour,   145, 

ulcer.     See  "  Gastric  Ulcer." 


STONE 

in  bladder 
kidney 
See  "  Calculus," 


STOOLS     • 

character  of,  176. 


STKANGULATED    HERNIA,    170. 

STRICTURE 

of  oesophagus,  130. 


STRUCTURAL    SYMPTOMS,  21, 
of  bladder,  192. 

digestive  tube,  177. 
pall-stone  disease,  161. 
kidneys,  179. 


314  Index. 

STRUCTURAL    SYMPTOMS— cowftwwetZ. 
of  liver  afiections,   165. 

respiratory  affections,  213. 
stomach  affections,   145. 

SUFFOCATION 

sense  in  heart  affections,  226. 

SUPERFICIAL    REFLEX,    86  (fig.),  139. 

SWALLOWING,  127. 

hot  and  cold  fluids,  129. 

ice,  pain  in,  135. 

in  angina  pectoris,  124. 

painful,  125. 

spasm  in,  130. 

SYMPATHETIC  NERVES.     See  "  Autonomic." 
to  stomach,  134. 

SYMPTOMS 

bearing  on  prognosis,  258. 
treatment,  262. 
functional,  20.     See  "  Functional." 
motor,  110. 
of  affections  of  bladder,  189. 

cerebro-spinal  nerves,  109. 

heart,  222. 

intestines,  167. 

liver,  gall-bladder  and  ducts,  156. 

limgs  and  pleura,  209. 

peritoneum,  199. 

stomach,  131. 

urinary  system,  178. 
peritoneal  adhesions,  parietal,   200. 
visceral,  202. 
reflex,  17,  84. 
relation  of,  1,  251,  256. 
relative  importance  of,  21. 
sensory,  110. 

in  digestive  tract,  116. 
structural.  See  "  Structural." 
value  of,  251. 


Index. 


SYNOVIAL    MEMBRANE 
sensitiveness  of,  112. 

SYSTEM,    NERVOUS 
constitution  of,  25. 
development  of,   19. 


T 

TACHYCARDIA,  163,  226,  233. 

TEETH 

false,  inflammation  from,  125. 

TEMPERAMENTS,  104. 

neurotic,  104,  142,  226,  252. 

TENDER 

ovary,  195, 
vertebrae,  68. 

TESTICULAR    PAIN,    36,    66. 

in  renal  colic,  46,  101,  181,  184. 

THORACIC    NERVES 

distribution,  94  (fig.),  96,  135. 

TIC    DOULOUREUX,  124. 

TONGUE,  126. 

TONSILITIS,  128. 

TONSILS 

inflamed,  125. 

in  svvallowuig,  127. 

TOOTHACHE,  30,  123,  261. 


316  Index. 

TREATMENT 

as  factor  iu  diagnosis,  265. 
bearing  on  symptoms  on,  262. 
of  affections  of  heart,  265. 

stomach,  146,  267. 

TRIGEMINAL    NEURALGIA,    124. 

TUBERCULOUS    ULCER 
of  colon,  75. 

TUMOUR 

abdominal,  55,  72,  177,  202. 
in  stomach,  145. 
ovarian,  203. 

TUNICA    VAGINALIS,  38. 

TYPHOID    FEVER 

facial  aspect,  103. 
stools,  177. 


U 

ULCER 

gastric.     See  '*  Gastric." 
tubercular,  of  colon,  75. 

ULCERATION 

of  pelvis  of  kidney,  181. 
rectum,  175. 
ureter,   181. 

UMBILICAL    FISTULA 

pain  in  operation  for,  39. 

URETHRAL    CARUNCLE,  196. 

URETER 

affections  of,  180. 
nerve-supply,  180. 
peristalsis,   182,   184. 
site  of  stone  in,  182,  184. 


Index.  317 


UEINAEY    SYSTEM 

affections  of,  179. 
inquiry  into,  106. 

UKINE 

albumen  in,  178,  179,  261. 

retention  of,  189. 

secretion,  in  angina  pectoris,  247. 

UTERUS,  194. 

areas  of  pain  in  affections  of,  69  (fig.), 
paiia  in,  119,  193. 


V 

VAGINA,  196. 

VAGUS    NERVE,    134,    157,    246. 

VALUE 

of  symptoms,  251. 

VALVULAR    IMPERFECTION 

of  heart,  222,  237,  252. 

VASOMOTOR    REFLEXES,    82. 

VERTEBRAE 

diseased,  70. 
tender,  68. 

VERTEBRATE    ANIMAL 

primitive,  94  (fig.). 

VISCERA 

hollow,  pain  in,   119. 
insensitiveness  of,  33. 
sensation  in,  8. 


318  Index. 

VISCERAL 

disease,  cutaneous  hyperalgesia,  64. 
pain  in,  41,  114. 
reflex  in,  48. 
lesion,  localisation  of,  93. 
pain,  26,  32,  39,  46,  87  (fig.),  118. 
artificial  production,  38. 
radiation  of,  46. 

VISCERO-MOTOR  REFLEX,  10,  42,  71,  87  (fig.),  88,  139, 
230,  243. 

VISCERO-SENSORY    REFLEX,    42,    230,    233,    236. 

VOMITING,  78,  140,  164,  196. 


W 

WATER-BRASH,    141. 

WHITLOW 

pain  in,  29. 


X-RAYS 

in  examination  of  digestive  tract,   144,  168, 


HOEBER^S 
MEDICAL  MONOGRAPHS 


MEDICAL   MONOGRAPHS 

Published  by 
PAUL  B.   HOEBER 

67^69  East  59th  St.,  New  York 

This  catalogue  com'prises  only  our  own  Tpublications.  It  will 
be  noticed  that  particular  care  has  been  exercised  in  the  selec- 
tion of  Monographs  of  timely  interest. 

We  are  always  glad  to  consider  the  publication  of  new  and 
original  medical  works.  Correspondence  with  Authors  is 
invited. 

ADAM:     Asthma  and  Its  Radical  Treatment.     By  James 
Adam,    m.a.,    m.d.,    f.r.c.p.s.      Hamilton.     Dispensary   Aural 
Surgeon,  Glasgow  Royal  Infirmary. 
8vo,  Cloth,  viii+184  Pages,  Illustrated $1.50  net, 

ADLER:     Compendium  of  Histo-Pathological  Technic.   By 
Emma  H.  Adler.     Formerly  Technician  Pathological  Labora- 
tory, Presbyterian  Hospital,  New  York. 
12mo,    Cloth    In  Press. 

ADLER:  Primary  Malignant  Growths  of  the  Lungs  and 
Bronchi.  By  I.  Adler,  a.m.,  m.d..  Prof.  Emeritus  New  York 
Polyclinic,  Consulting  Physician,  German,  Beth-Israel,  Har 
Moriah,  People's  and  Montefiore  Hospitals.  8vo,  Cloth,  xii-}- 
325  Pages,  1  Colored  and  16  Halftone  Plates $2.50  net. 

AMERICAN     JOURNAL     OF     ROENTGENOLOGY,     THE. 
OfTicial    Organ    of    the    American    Roentgen    Ray    Society. 
Edited  by  James  T.  Case,  m.d..  Battle  Creek,  Mich. 
Published  monthly.   Vol.  V,  No.  1,  Jan.,  1918.  .$5.00  per  year. 

Anatomical   Charts.      (See  BLAINE.) 

ANNALS  OF  MEDICAL  HISTORY.  Edited  by  Francis  R. 
Packard,  m.d.  Associatw  Editors:  Drs.  Harvey  Cushing, 
George  Dock,  Mortimer  Frank,  Fielding  H.  Garrison,  Abra- 
ham .lacobi,  Howard  A.  Kelly,  Arnold  C.  Klebs,  Sir  William 

3 


4  HOEBEB'S  MEDICAL  MONOGEAPHS 

Osier,   William  Pepper,   Lewis   S.   Pilcher,   David    Kiesman, 

Chas.  Singer  and  Edward  C.  Streeter. 

Published  quarterly $6.00  per  year. 

AEMSTEONG:     I.  K.  Therapy,  with  Special  Eefeeence  to 
Tuberculosis.     By  W.  E.  M.  Armstrong,  m.a.,  m.d.  Dublin. 
Bacteriologist  to  Cent.  Lond.  Ophthalmic  Hosp.,  Late  Asst. 
in  Inoculation  Dept.,  St.  Mary's  Hosp.,  Padding,  W. 
8vo,  Cloth,  x-f93  Pages,  Illustrated $1.50  net. 

BACH:     Ultea- Violet  Light  by  Means  of  the  Alpine  Sun 
Lamp.    By  Hugo  Bach,  m.d..  Bad  Elster,  Germany.    Author- 
ized Transl.  from  German. 
12mo,  Cloth,  114  Pages,  Illustrated .$1.00  net. 

BARRINGER,  JANEWAY  AND  FAILLA:  Eadium  Therapy 
IN  Cancer  at  the  Memorial  Hospital.  (See  Janeway,  Bar- 
ringer  and  Failla.) 

BIGG:  Indigestion,  Constipation  and  Liver  Disorder.  By 
G.  Sherman  Bigg,  Fellow  of  the  Eoyal  College  of  Surgeons; 
Fellow  of  the  Eoyal  Institute  of  Public  Health ;  Late  Surgeon 
Captain,  Army  Medical  Staff;  Surgeon  Allahabad,  India. 
12mo,  Cloth,  viii+168  Pages $1.50  net. 

BLAINE:  Anatomical  Charts,  especially  arranged  by  Ed- 
ward S.  Blaine,  m.d.,  for  the  graphic  recording  of  roentgen 
or  surgical  findings.  These  show  (A)  complete  skeleton, 
dorsal,  ventral  and  left  and  right  side  views — also  with 
outline  of  internal  organs  in  color,  if  desired;  (B)  skeleton 
of  head,  dorsal,  ventral,  left  and  right  side,  and  top  views, 
enlarged;  (C)  Torso,  dorsal,  ventral,  left  and  right  side 
views,  enlarged — also  with  outline  of  internal  organs  in 
color;  (D)  upper  extremities,  enlarged  view;  (E)  lower 
extremities,  enlarged  view.  Will  be  made  up  to  meet  the 
individual  needs  of  the  specialist  or  general  practitioner. 

BLAND-SUTTON:  Tumours:  Innocent  and  Malignant. 
Their  Clinical  Characters  and  Appropriate  Treatment.  By 
Sir  John  Bland-Sutton,  ll.d.,  f.r.c.s.,  Surgeon  to,  and  Chair- 
man of  the  Cancer  Investigation  Committee  of  the  Middlesex 
Hospital.  Sixth  edition. 
8vo,  Cloth,  ix4-790  Pages,  with  338  Illustrations.  .$7.00  net. 

BEAUN  AND  FEIESNER:  Cerebellar  Abscess:  Its  Eti- 
ology, Pathology,  Diagnosis  &  Treatment,  (See  Friesner  & 
Braun.) 

BEOCKBANK:  The  Diagnosis  and  Treatment  of  Heart 
Disease.  Practical  Points  for  Students  and  Practitioners. 
By  E.  M.  Brockbank,  m.d.  (Vict.),  f.r.c.p.,  Hon.  Phys.  Royal 


HOEBER'S   MEDICAL   MOXOGEAPHS  5 

Infirmary,  Manchester,  Clin.  Lecturer  Diseases  of  the  Heart, 

Dean  of  Clin.  Instruction,  University  of  Manchester. 

12mo,  Cloth,  3d  Edition,  148  Pages,  Illustrated.  .$1.75  net. 

BROWNE:  Eeligio  Medici,  Letters  to  a  Friend,  etc.,  and 
Christian  Morals,  with  Preface  by  Drs.  Osier  and  Packard. 

In  Preparation. 

BRUCE:  Lectures  on  Tuberculosis  to  Nurses.  Based  on 
a  course  delivered  to  the  Queen  Victoria  Jubilee  Nurses. 
By  Olliver  Bruce,  .loint  Tuberculosis  Officer,  County  of  Essex. 
12mo,  Cloth,  124  Pages,  Illustrated $1.00  net. 

BRUNTON:     Therapeutics    of   the    Circulation.     By    Sir 
Lauder     Brunton,     m.d.,     d.sc,    ll.d.    Edin.,    ll.d.     Aberd., 
F.R.C.P.,   F.R.s.      Consulting  Physician   to   St.   Bartholomew's 
Hospital.     Second  Edition,  Entirely  Revised. 
Cloth,  xxiv-|-536  Pages,   110   Illustrations $2.50  net. 

BULKLEY:     Ca.vcer:     Tts  Cause  and  Treatment,  Volume 
I.     By  L.  Duncan  BuLkley. 
8vo,  Cloth.   224   Paycs $1.50  net. 

BULKLEY:  Cancer:  Its  Cause  and  Treatment,  Volume  ii. 
By  L.  Duncan  Bulkley.     8vo,  Cloth,  272  Pages $1.G0  net. 

BULKLEY:  Compendium  of  Diseases  of  the  Skin.  Based 
on  an  analysis  of  thirty  thousand  consecutive  cases.  With 
a  Therapeutic  Formulary,  by  L.  Duncan  Bulkley,  a.m., 
M.D.  Physician  to  the  New  York  Skin  and  Cancer  Hospital; 
Consulting  Physician  to  the  New  Y''ork  Hospital. 
8vo,  Cloth,  xviii-f  286  Pages $2.00  net. 

BULKLEY:     Diet  and  Hygiene  in  Diseases  of  the  Skin. 
By  L.  Duncan  Bulkley. 
8vo,  Cloth,  xvi-f  194  Pages $2.00  net. 

BULKLEY:  The  Influence  of  the  Menstrual  Function 
on  CEkTAiN  Diseases  of  the  Skin.  By  L.  Duncan  Bulkley. 
12mo,  Cloth,  108  Pages $1.00  net. 

BULKLEY:  Principles  and  Application  of  Local  Treat- 
ment IN  Diseases  of  the  Skin.  By  L.  Duncan  Bulkley. 
12mo,  Cloth,  130  Pages $1.00  net. 

BULKLEY:     The  Relations  of  Diseases  of  the  Skin  to 
Internal  Disorders:  With  Observations  on  Diet,  Htgiens 
AND  General  Therapeutics.     By  L.  Duncan  Bulkley. 
12mo,  Cloth,   175   Pages $1.50  net. 

BULLETIN:     See  Neurological  Bulletin. 

CARLETON:  The  Seriousness  of  Venereal  Diseases.     By 
Sprague   Carleton,   m.d.,   f.a.c.s..   Special   Publication.     Sec- 
ond Edition. 
12mo,  67  Pages,  26  Illustrations 50c  net. 


6  EOEBEB'S  MEDICAL  MONOGRAPHS 

CAREEL  AND  DEHELLY:  The  Treatment  of  Infected 
Wounds.  By  A.  Carrel  and  G.  Dehelly.  Authorized  Transla- 
tion from  the  French  by  Herbert  Child,  m.d.,  Formerly  Sur- 
geon, French  Eed  Cross,  Capt.  r.a.m.c.  (Ty.),  with  an 
Introduction  by  Sir  Anthony  A.  Bowlby,  f.r.c.s.,  Temporary 
Surgeon  General,  Army  Medical  Service.  Second  Edition. 
12mo,  Cloth,  265  Pages,   114  Illustrations $2.50  net. 

adopted  by  u.  s.  army. 

CAREEL  AND  DUMAS :  Technic  of  the  Irrigation  Treat- 
ment OF  Wounds  by  the  Carrel  Method.  By  J.  Dumas, 
and  Anne  Carrel.  Authorized  translation  by  Adrian  V. 
S.  Lambertj  m.d.,  Acting  Professor  of  Surgery,  College  of 
Physicians  and  Surgeons  (Columbia  University),  New  York 
City.  Introduction  by  W.  W.  Keen,  m.d.,  ll.d.,  f.r.c.s.  (Hon.). 
12mo,  Cloth,  90  pages,  11  plates $1.25  net. 

CAUTLEY:     The  Diseases  of  Infants  and  Children.     By 
Edmund  Cautley,  m.d.  Cantab.,  f.r.c.p.  Lond.     Senior  Physi- 
cian to  the  Belgrave  Hospital  for  Children,  etc. 
Large  8vo,  Cloth,  1042  Pages $8.00  net. 

CLARKE :    Problems  in  the  Accommodation  and  Refraction 
OF  the  Eye,  a  Brief  Review  of  the  Work  of  Donders, 
and  the  Progress  Made  During  the  Last  Fifty  Years.  By 
Ernest   Clarke,    m.d.,    b.s.,    f.r.c.s. 
8vo,  Boards,  110  Pages $1.00  net. 

COLLINS :     Neurological  Clinics.     Exercises  in  the  Diagno- 
sis of  Mental  Diseases  of  the  Nervous  System  as  discussed  at 
the  Neurological  Institute,  New  York  City.    Edited  by  Joseph 
Collins,  M.D. 
8vo,  Cloth,  271  Pages,  Illustrated In  Press. 

COOKE:  The  Position  of  the  X-Rays  in  the  Diagnosis 
AND  Prognosis  of  Pulmonary  Tuberculosis.     By  W.  E. 

Cooke,   M.B.,   M.R.C.P.E.,   D.p.H.    (Lond.). 

8vo,  Cloth,  Illustrated $1.50  net. 

COOPER:     Pathological    Inebriety.     Its    Causation    and 
Treatment.     By   J.   W.   Astley   Cooper.     Medical   Superin- 
tendent and  Licensee  of  Ghyllwood  Sanatorium,    With  Intro- 
duction by  Sir  David  Terrier,  m.d.,  f.r.S. 
12mo,  Cloth,  xvi-flSl  Pages $1.50  net. 

COOPER:     The   Sexual   Disabilities   of   Man,   and    Their 
Treatment.    By  Arthur  Cooper.    Consulting  Surgeon  to  the 
Westminster  General  Dispensary,  London. 
3rd  Edition,  12mo,  Cloth,  viii+227  Pages $2.50  net. 

CORBETT-SMITH :  The  Problem  of  the  Nations.  A  Study 
in  the  Causes,  Symptoms  and  Effects  of  Sexual  Disease,  and 
the  Education  of  the  Individual  Therein.     By  A.  Corbett- 


EOEBEE'S  MEDICAL  MONOGBAPHS  7 

Smith,  Editor  of  The  Journal  of  State  Medicine;  Lec- 
turer in  Public  Health  Law  at  the  Eoyal  Institute  of  Public 
Health.    Large  8vo,  Cloth,  xii+107  Pages $L00  net. 

COENET :     Acute  General  Miliary  Tubercxjlosis.    By  Prof. 
Dr.  G.  Cornet,  Berlin.     Transl.  by  F.  S.  Tinker,  b.a.,  m.b. 
8vo,  Cloth,  viii-f  107  Pages $1.50  net. 

CROOKSHANK:     Flatulence  and  Shock.    By  F.  G.  Crook- 
Bhank,  m.d.  Lond.,  m.e.c.p.    Physician  (Out  Patients)  Hamp- 
stead  General  and  N.  W.  Lond.  Hospital. 
8vo,  Cloth,  iv+47  Pages $1.00  net. 

DAVIDSON:     Localization    by    X-Eays    and    Stereoscopy. 
By  Sir  James  Mackenzie  Davidson,  m.b.,  cm.  Aberd.     Con- 
sulting  Medical   Officer,    Roentgen   Ray    Department,    Royal 
London  Ophthalmic  Hospital. 
Svo,  Cloth,  72  pp.,  Plates  and  58  Stereo.  Figs $3.00  net. 

DAWSON:     The  Causation  op  Sex  in  Man.    By  E.  Rumley 
Dawson,  l.r.c.p.  Lond.,  m.r.c.s.  England. 
Svo,  Cloth,  240  Pages,  with  21  Illustrations $3.00  net. 

DELORME:  War  Surgery.  By  Edmond  Delorme,  General 
Medical  Inspector  of  the  French  Army.  Translated  by  D. 
De  Meric,  Surgeon  to  In-Patients,  French  Hospital,  London. 
12mo,  Cloth,  Illustrated,  248  Pages $1.50  net. 

DUMAS  AND  CARREL:  Technic  of  the  Irrigation  Treat- 
ment of  Wounds  by  the  Carrel  Method.  (See  Carrel  and 
Dumas.) 

EDRIDGE-GEEEN:     The  Hunterian  Lectures  on  Coloub- 
VisiON  AND  CoLouE  BLINDNESS.     Delivered  before  the  Eoyal 
College  of  Surgeons  of  England  on  February  1st  and  3rd, 
1911.     By  Professor  F.  W.  Edridge-Green,  m.d.,  f.r.c.s. 
8vo,  Cloth,  X4.76  Pages $1.50  net. 

EHELICH:  Experimental  Researches  on  Specific  Thera- 
peutics. By  Prof.  Paul  Ehrlich,  m.d.,  d.sc.  Oxon.  The 
Harben  Lectures  for  1907  of  Eoyal  Institute  of  Public  Health. 
16mo,  Cloth,  X4-95  Pages $1.00  net. 

EINHORN:      Lectures    on    Dietetics.      By    Max    Einhorn, 
Professor  of  Medicine  at  N.  Y.  Post-Graduate  Med.  School 
and  Hospital,  Visit.  Phys.  German  Hospital,  N.  Y. 
12mo,  Cloth,  xvi+156  Pages $1.25  net. 

ELLIOT :  Glaucoma.  By  Col.  Robert  Henry  Elliot,  m.d.,  f.r.c.s. 
8vo,  Cloth,  60  Pages,  with  23  Illustrations $1.50  net. 

ELLIOT:  The  Indian  Operation  of  Couching  for  Catar- 
act, Incorporating  the  Hunterian  Lectures  delivered  before 
the  Royal  College  of  Surgeons  of  England  on  February  19 


8  HOEBEB'S  MEDICAL  MONOGBAPHS 

and  21,  1917.     By  Robert  Henry  Elliot,  M.D.,  B.   S.  Lend., 

sc.D.,  Edin.,  F.R.C.S.,  Eng.,  etc. 

8vo.,  Cloth,  94  Pages,  45  illustrations In  Press. 

ELLIOT:  Sclero-Corneal  Trephining  in  the  Operative 
Treatment  op  Glaucoma.  By  Robert  Henry  Elliot,  m.d., 
B.s.  Lond.,  D.sc.  Edin.,  f.r.c.s.  Eng.  Lieut.  Colonel  i.M.s. 
2d  Ed.     Svo,  Cloth,  135  Pages,  33  Illus $3.00  net. 

EMERY:  Immunity  and  Specific  Therapy.  By  Wm.  D'Este 
Emery,  m.d.,  b.sc.  Lond.  Clinical  Pathologist  to  King's 
College  Hospital  and  Pathologist  to  the  Children's  Hospital. 

Svo,  Cloth,  448  Pages,  with  2  Illustrations $3.50  net. 

adopted  by  the  u.  s.  army. 

EMERY:     Tumors,   Their   Nature   and   Causation.     By   Wm. 
D'Este  Emery,  m.d.,  b.sc,  Lond.     Director  of  Laboratories, 
King's  College  Hospital,  Captain  r.a.m.c.  (T.  F.). 
12mo,  Cloth,  146  Pages In  Press. 

FAILLA,  JANEWAY  AND  BARRINGER:  Radium  Therapy 
in  Cancer  at  the  Memorial  Hospital.  (See  Janeway,  Bar- 
ringer  and  Failla.) 

FISHBERG:     The  Internal  Secretions.     (See  Gley.) 

FRIESNER  AND  BRAUN:  Cebebellat.  Abscess;  Its  Eti- 
ology, Pathology,  Diagnosis  and  Treatment.  By  Isidore 
Friesner,  m.d.,  f.a.c.s.,  Adjunct  Professor  of  Otology  and 
Assistant  Aural  Surgeon,  Manhattan  Eye,  Ear  and  Throat 
Hospital  and  Post- Graduate  Medical  School,  and  Alfred 
Braun,  M.D.,  f.a.c.s.,  Assistant  Aural  Surgeon,  Manhattan 
Eye,  Ear  and  Throat  Hospital,  Adjunct  Professor  of 
Laryngology,  New  York  Polyclinic  Hospital  and  Medical 
School  and  Adjunct  Otologist,  Mt.  Sinai  Hospital. 
Svo,  Cloth,  186  Pages,  10  Plates,  16  Illus $2.50  net. 

GERSTER:     Recollections  of  a  New  York  Surgeon.     By 
Arpad  G.  Gerster,  m.d. 
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GHON:     The    Primary    Lung    Focus    of    Tuberculosis    in 
Children.     By   Anton   Ghon,   m.d.,   English   Translation   by 
D.  Barty  King,  m.a.,  m.d.  Edin.,  m.r.c.p. 
Large  Svo,  Cloth,  196  pp.,  72  Illus.,  2  Plates $3.75  net. 

GILES:     Anatomy  and  Physiology  op  the  Female  Genera- 
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b.sc.  Lond.,  m.r.c.p.  Lond.;  f.r.c.s.  Ed.     Gynecologist  to  the 
Prince  of  Wales  General  Hospital. 
Large  Svo,  24  Pages,  with  Mannikin $1.50  net. 

GLEY:  The  Internal  Secretions.  By  E.  Gley,  m.d.  Mem- 
ber  of   the   Academy   of   Medicine   of   Paris,   Professor   of 


HOEBEB'S  MEDICAL  MONOGBAPES  9 

Physiology  in  the  College  of  France,  etc.  Authorized  Trans- 
lation. Translated  and  Edited  by  Maurice  Pishberg,  m.d. 
8vo,  Cloth,  241  Pages $2.00  net. 

GOULSTON:  Cane  Sugar  and  Heart  Disease.  By  Arthur 
Goulston,  M.A.,  M.D.  Cantab.  Hunterian  Society  'a  Medallist, 
1912.    8vo,  Cloth,  107  Pages $2.00  net. 

GEEEFF:  Guide  to  the  Microscopic  Examination  op  the 
Eye.  By  Professor  R.  Greeff.  Director  of  the  University 
Ophthalmic  Clinique  in  the  Eoyal  Charity  Hospital,  Berlin. 
With  the  co-operation  of  Professor  Stock  and  Professor 
Wintersteiner.  Translated  from  the  third  German  Edition 
by  Hugh  Walker,  m.d.,  m.b.,  cm. 
Large  8vo,  Cloth,  86  Pages,  Illustrated $2.00  net. 

GREEN,  EDRIDGE-:  The  Hunterian  Lectures  on  Colour 
Vision  and  Colour  Blindness.     (See  Edridge-Green.) 

HARRIS:     Lectures   on   Medical   Electricity  to   Nurses. 
An  Illustrated  Manual  bv  J.  Delpratt  Harris,  M.D.,  u.R.c.s. 
12mo,  Cloth,  88  Pages,  illustrated $1.00  net. 

HELLMAN:     Amnesia    and    Analgesia    in    Parturition — 

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8vo,  Cloth,  with  Charts,  200  Pages $1.50  net. 

HEWATT:     The    Examination    of    the    Urine,    and    Other 

Clinical  Side  Room  Methods.     By  Andrew  Fergus  Hewatt, 

M.B.,  ch.b.,   m.r.c.p.   Edin. 

16mo,  5th  Edition,  Numerous  Illustrations $1.00  net. 

HOFMANN-GARSON:  Remedial  Gymnastics  for  Heart 
Affections.  Used  at  Bad-Nauheim.  Being  a  Translation 
of  "Die  Gymnastik  der  Herzleidenden"  von  Dr.  Med.  Julius 
Hofmann  und  Dr.  Med.  Ludwig  Pohlman.  Berlin  and  Bad- 
Nauheim.  By  John  George  Garson,  m.d.  Edin.,  etc.  Physi- 
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Large  8vo,  Cloth,  144  Pages,  51  Full-page  Illus $2.00  net. 

HOWARD:     The   Therapeutic  Value  op   the   Potato.     By 
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8vo,  Paper,  vi-|-31  Pages,  Illustrated 50c  net. 

JANEWAY,  BARRINGER  AND  FAILA :  Radium  Tiier.^py 
IN  Cancer  at  the  Memorial  Hospital,  Report  of  19151916. 
By  Henry  H.  Janeway,  m.d.,  with  the  Discussion  of  the 
Treatment  of  Cancer  of  the  Prostate  and  Bladder  by  Ben- 
jamin S.  Barringer,  m.d.,  and  an  Introduction  upon  the 
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JELLETT:  A  Short  Practice  op  Midwifery  for  Nurses. 
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Dublin.     By  Henry  Jellett,  b.a.,  m.d.     (Dublin  University), 


10  HOEBEB'S  MEDICAL  MONOGRAPHS 

F.R.C.P.I.,   Master  Eotunda   Hospital.     With  Six  Plates  and 
169  Illustrations  in  the  Text,  also  an  Appendix,  a  Glossary 
of  Medical  Terms,  and  the  Eegulations  of  the  Central  Mid- 
wives  Board. 
12mo,  Cloth,  xvi-|-508  Pages $2.50  net. 

JONES:     Notes  on  Military  Orthopedics.    By  Col.  Robert 
Jones,  C.B.,  Inspector  of  Military  Orthopaedics,  Army  Med- 
ical Service. 
8vo,  Cloth,  132  Pages,  95  Illustrations $1.50  net. 

KENWOOD:  Publio  Health  Laboeatoey  Woek.  By  Henry 
R.  Kenwood,  m.b.,  f.r.s.  Edin.,  p.p.h.,  p.c.s.,  Chadwick 
Prof,  of  Hygiene  and  Public  Health,  University  of  London. 
6th  Edition,  8vo,  Cloth,  418  Pages,  Illustrated $4.00  net. 

KERLEY:     What  Evert  Mother  Should  Know  About  Hkb 
Infants  and  Young  Children.    By  Charles  Gilmora  Kerley, 
M.D.     Professor   of   Diseases   of   Children,   N.   Y.   Polyclinic 
Medical    School    and    Hospital. 
8vo,  Paper,   107  Pages 35c  net. 

KETTLE:  The  Pathology  op  Tumors.  By  E.  H.  Kettle, 
M.D.,  B.s,,  Assistant  Pathologist,  St.   Mary's   Hospital,   and 

Assistant  Lecturer  on  Pathology,  St.  Mary 's  Hospital. 
8vo,'  Cloth,  242  Pages,  126  Illustrations $3.00  7iet. 

LEWERS:  A  Practical  Textbook  op  the  Diseases  of 
Women.  By  Arthur  H.  N.  Lewers,  m.d.  Lond.  Senior 
Obstetric  Physician,  London  Hospital. 

With  258  Illustrations,  13  Colored  Plates,  5  Plates  in  Black 
and  White.   7th  Ed.,  8vo,  Cloth,  xii+540  Pages $4.00  net. 

LEWIS:  Clinical  Disorders  of  the  Heart  Beat.  A  Hand- 
book for  Practitioners  and  Students.  By  Thomas  Lewis,  m.d., 
D.sc,  F.R.c.P.     Assistant  Physician  and  Lecturer  in  Cardiac 

Pathology,  University  College  Hospital  Medical  School. 

.4th  Ed.,  8vo,  Cloth,  120  Pages,  54  Illustrations.  .  .$2.25  net. 

LEWIS:     Lectures  on  the  Heart.     Comprising  the  Herter 
Lectures   (Baltimore),  a  Harvey  Lecture   (New  York),  and 
an  Address  to  the  Faculty  of  Medicine  at  McGill  University 
(Montreal).     By  Thomas  Lewis. 
124  Pages,  with  83  Illustrations $2.00  net. 

LEWIS :    Clinical  Electrocardiography.    By  Thomas  Lewis. 

2nd  Ed.    8vo,  Cloth,  120  Pages,  with  Charts $2.25  net. 

LEWIS :  The  Mechanism  of  the  Heart  Beat.  With  Special 
Reference  to  Its  Clinical  Pathology.  By  Thomas  Lewis. 
Large  8vo,  Cloth,  295  Pages,  227  Illus $7.00  net. 

McCLURE:  A  Handbook  of  Fevers.  By  J.  Campbell  Mc- 
Clure,     M.D.,     Glasgow,       Physician     to     Out-Patients,     The 


HOEBER'S  MEDICAL  MONOGEAPHS  11 

French  Hospital,  and  Physician  to  the  Margaret  Street 
Hospital  for  Consumption  and  Diseases  of  the  Chest,  London. 
8vo,  Cloth,  470  Pages,  with  Charts $3.50  net. 

McCEUDDEN:    The  Chemistry,  Physiology  and  Pathology 
OF  Ueic  Acid,  and  the  Physiologically  Important  Pubin 
Bodies.     With  a  Discussion  of  the  Metabolism  in  Gout.     By 
Francis    H.    McCrudden. 
12mo,  Paper,  318  Pages $2.00  net. 

McKISACK:    Systematic  Case  Taking.     A  Practical  Guide 
to  the  Examination  and  Recording  of  Medical  Cases.     By 
Henry  Lawrence  McKisack,  m.d.,  m.r.c.p.  Lond. 
12mo,  Cloth,  166  Pages $1.50  net. 

MACKENZIE:  Symptoms  and  Their  Interpretation.  By 
James  Mackenzie,  m.d.,  ll.d.  Aber.  and  Edin.  Second  Edition. 
Svo,  Cloth,  Illustrated,  xxii+318  Pages $3.75  net. 

MACKENZIE :  Action  of  the  Muscles.  By  Collin  W.  Mac- 
kenzie     In  Press. 

MACMICHAEL:  The  Gold-Headed  Cane.  By  William  Mac- 
michael.  Eeprinted  from  the  2nd  Edition.  With  a  Preface 
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MAGILL:     Notes  on  Galvanism  and  Faradism.     By  E.  M. 
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12mo,   Cloth,   220  Pages,   67   Illustrations $1.50  net. 

MARTINDALE    and    WESTCOTT:     "Salvarsan"    "606" 
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burg,  F.C.S.,  and  W.  Wynn  Westcott,  m.b. 
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MINETT  :    Diagnosis  of  Bacteria  and  Blood  Parasites.    By 

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MITCHELL:  Memoranda  on  Army  General  Hospital  Ad- 
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Commanding  No.  43  General  Hospital. 

8vo,   Cloth,   v-l-109   Pages,   Illustrated   with   vii   plates 

In  Press. 

MOTT  :    Nature  and  Nurture  in  Mental  Development.    By 

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County  Asylums. 

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12  HOEBEE'S  MEDICAL  MONOGRAPHS 

MUERELL:     What  To  Do  in  Cases  of  Poisoning.    By  Wil- 
liam Murrell,  m.d.,  f.r.c.p.     Senior  Physician  to  the  West- 
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11th  Edition,  16mo,  Cloth,  283  Pages $1.00  net. 

Neurological  Bulletin.  Clinical  Studies  of  Nervous  and 
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ciate Editor,  Louis  Casamajor,  m.d.;  Editorial  Board:  S.  P. 
Goodhart,  m.d.,  F.  M.  Hallock,  m.d.,  Eandal  Hoyt,  m.d.,  C. 
A.  McKendree,  m.d.,  Michael  Osnato,  m.d.,  Oliver  S.  Strong, 
PH.D.,  I.  S.  Weehsler,  m.d.     Published  monthly.  .$3.00  a  year. 

OLIVER:  Lead  Poisoning:  From  the  Industrial,  Medical 
and  Social  Point  of  View.  Lectures  Delivered  at  Royal  Insti- 
tute of  Public  Health.  By  Sir  Thomas  Oliver,  m.a.,  m.d.,  f.r.c.p. 
12mo,  Cloth,  294  Pages $2.00  net. 

OLIVER:     Studies  in  Blood  Pressure,  Physiological  and 
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W.  A.  Halliburton,  m.d.,  f.r.s. 
8vo,  Cloth,  xxiv,  240  Pages,  Illustrated $3.00  net. 

OSLER:  Two  Essays.  By  Sir  William  Osier,  m.d.  Regius 
Professor  of  Medicine  at  Oxford. 

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12mo,  Cloth,  168  Pages,  Illustrated $1.50  net. 

PAGET :    For  and  Against  Experiments  on  Animals.    Evi- 
dence   before    the    Royal    Commission    of    Vivisection.      By 
Stephen  Paget,  F.R.c.s.     With  an  Introduction  by  The  Right 
Hon.   The   Earl  of  Cromer. 
8vo,  Cloth,  Illustrated,  xii4-344  Pages $1.50  net. 

PEGLER:  Map  Scheme  of  the  Sensory  Distribution  of 
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RAWLING:      Landmarks   and  Surface   Markings   of   the 
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EOEBEB'S  MEDICAL  MONOGEAPES  13 

REPORT  OF  RADIUM  THERAPY  IN  CANCER  AT  THE 
MEMORIAL  HOSPITAL.  (See  Janeway,  Barringer  and 
Failla.) 

RITCHIE :  Auricular  Flutter.  By  William  Thomas  Ritchie, 
M.D.,  F.R.C.P.E.,  F.R.s.E.  Physician  to  the  Royal  Infirmary. 
Large  8vo,  Cloth,  156  Pages,  21  Plates,  107  Illus.  .$3.50  net. 

RUTHERFORD :  The  Ileo-C^cal  Valve.  By  A.  H.  Ruther- 
ford, M.D.  Edin.  8vo,  Cloth,  63  Pages  of  Text,  23  Full  Page 
Plates,    3    Colored $2.25    net. 

SAALFELD  :  Lectlties  ok  Cosmetic  Treatment.  A  Manual 
for  Practitioners.  By  Dr.  Edmund  Saalfeld  of  Berlin. 
Translated  by  J.  F.  Dally,  m.a.,  m.d.,  b.c.  Cantab., 
M.R.c.p.  Lond.  With  an  Introduction  and  Notes  by  P.  S. 
Abraham,  m.a.,  m.d.,  b.sc,  f.r.c.s.i. 
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SCHOOL  OF  SALERXUM,  THE,  Including  Regimen  Sani- 
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•  a  Note  on  the  Prehistory  of  the  Regimen  Sanitatis  by  Field- 
ing H.  Garrison,  m.d.     Illustrated hi  Press. 

SCOTT :  Modern  Medicine  and  Some  Modern  Remedies.  By 
Thomas  Bodley  Scott,  with  a  Preface  by  Sir  Lauder  Brunton. 
12mo,  Cloth,  xv+159  pages $1.50  net. 

SCOTT:     The   Road   to   a   Healthy   Old   Age.     Essays   by 
Thomas  Bodley  Scott,  m.d. 
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SENATOR  and  KAMINER:  Marriage  and  Disease.  Being 
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©LOAN:     Electro-Therapy    in    Gynecology.      By    Samuel 
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Royal  Maternity  and  Women's  Hospital,  etc. 
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SMITH:  Studies  in  the  Anatomy  and  Surgery  of  the 
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SMITH:     Some  Common  Remedies,  and  Theib  Use  in  Pbao- 
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14  BOEBEB'S  MEDICAL  ilOXOGBAPHS 

SQUIER    and   BUGBEE:     Manual   of   Cystoscopy.     Bt   J. 

Bentley  Squier.   m.d.     Professor  of  Genito-Urinarv  Surgerv, 
Xew  York  Post-Graduate  Medical  School  and  Hospital,  and 
Henry  G.  Bugbee,  ii.D. 
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ADOPTED  EY   THE    U.    S.   ARMY.  ^ 

SQUIEE:  Traumatic  Ix.jl-bies  or  the  Kidneys  axd 
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Urology,  College  of  Physicians  and  Surgeons,  Columbia 
University,  Professor  of  Urology  and  Director  Department  of 
Urology,  Xew  York  Post  Graduate  Medical  School. 
12mo,  Cloth,  Illustrated  In  Press. 

STJlRK:  The  Growth  axd  Development  of  the  Baby.  A 
tabular  chart,  giving  the  result  of  personal  observation,  veri- 
fied by  authoritative  data,  as  to  development,  weight,  height, 
etc.,  during  the  first  seven  years.  By  Morris  Stark,  m.a.,  b.s., 
M.D.  Instructor  of  Pediatrics,  X.  Y.  Post-Graduate  Med.  Sch. 
Hea\-y  Paper,  20  by  25  inches 50c  net. 

STEPHENSON:     Eye-Stbaik    ik    Eveey-day    Peactick.      By 
Sidney  Stephenson,  m.b.,  cm.  Edin.,  d.o.  Oxon.,  f.b.c.s.  Edin 
Editor  of  the  Ophthalmoscope. 
8vo,   Cloth,   x-:-139   Pages $1.50   net. 

STEPHENSON:     A    Review    o?    Hobmoxe    Therapy.      1913. 

8vo,  Cloth,  viii+170  Pages $1.00  net. 

Bound    and    interleaved    edition    of    the    famous   "Hormone 

Number"  of  the  Prescriher    f Edinburgh). 

SWIETOCHOWSKI:      Mechaxo-Thzrapectics    in    Gexeral 
Practice.    By  G.  de  Swietochowski,  m.d.,  m.s.c.s.    Fellow  of 
the  Pioyal  Society  of  Medicine;  Clinical  Assistant,  Electrical 
and  Massage  Department,  King's  College  Hosp. 
12mo,  Cloth,  xiv-rl41  Pages,  31  Illustrations $1.50  net. 

TOUSEY:  Eoextgexogeaphic  Diagxosis  of  Dental  Infec- 
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8vo,  Cloth,  75  Pages  and  64  Illustrations .'..$1.50  net. 

Transactions   of   the   Twenty-Third   Annual   Meeting   op 
the   American    Laeyngological,    Ehinological    ant)    Oto- 
LOGiCAL  Society,  1917.     Paul  B.  Hoeber,  distributor. 
Svo,   Cloth,  vii-:-363   Pages,   with  Illustrations $3.50  net. 

TRUESDELL:  Birth  Fractures  and  Epiphyseal  Disloca- 
tions. By  Edward  D.  Truesdell,  M.D.,  Assistant  Attending 
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Large  Svo,  Cloth,  135  Pages,  151  Illustrations. ..  .$4.00  net. 

TLT?NER  and  PORTER:  The  Skiagraphy  of  the  Acces- 
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r.B.s.E.     Surgeon   to   the   Ear   and   Throat   Department,   the 


HOEBEB'S  MEDICAL  MONOGRAPHS  15 

Royal  Infirmary,  Edinburgh,  and  W.  G,  Porter,  M.B.,  B.sc, 
F.R.C.S.E.  Surgeon  to  Eye  and  Throat  Infirmary,  Edinburgh. 
Quarto,  Cloth,  45  Pages  of  Text,  39  Plates $5.00  net 

VON    RUCK    and    von    RUCK :     Studies  .  in    Immunization 
AGAINST    TiJBERCULOSis.      By    Karl    von    Ruck,    m.d.,    and 
Silvio  von  Ruck,  M.D. 
8vo,  Cloth,  xvi+-439  Pages $4.00  net. 

WANKLYN:  How  to  Diagnose  Smallpox.  A  Guide  for 
General  Practitioners,  Post-Graduate  Students,  and  Others. 
By  W.  McC.  Wanklyn,  b.a.  Cantab.,  M.B.cs.,  l.b,c.p.,  d.p.h. 
8vo,  Cloth,  102  Pages,  Illustrated $1.50  net. 

WATSON:  Gonorrhcea  and  Its  Complications  in  the  Mali 
AND  Female.  By  David  Watson,  m.b.,  cm.,  Surgeon,  Glasgow 
Lock  Hospital  Dispensary,  Surgeon  for  Venereal  Diseases, 
Glasgow  Royal  Infirmary,  etc.,  etc. 

8vo,  Cloth,  375  Pages,  72  Illustrations,  12  Plates,  Some  Col- 
ored  $3.75  net. 

WHITE :     The  Pathology  of  Growth.  Tumours.  By  Charles 
Powell    White,    m.c,    f.r.c.s.      Director,    Pilkington    Cancer 
Research  Fund,   Pathologist  Christie  Hospital,  Special  Lec- 
turer in   Pathology,  University  of  Manchester. 
Svo,  Cloth,  xvi+235  Pages,  Illustrated $3.50  net. 

WHITE :  Occupational  Affections  of  the  Skin.  A  brief 
account  of  the  trade  Processes  and  Agents  which  give  rise 
to  them.  By  P.  Prosser  White,  m.d.  Ed.,  m.r.c.s.  Lond.  Life 
Vice-President,  Senior  Physician  and  Dermatologist,  RoyaJ 
Albert  Edward  Infirmary. 
Svo,  Cloth,  165  Pages $2.00  net. 

WICKHAM  and  DEGRAIS:  Radium.  As  employed  in  the 
treatment  of  Cancer,  Angiomata,  Keloids,  Local  Tuberculosis 
and  other  affections.  By  Louis  Wickhara,  M.v.o.  MMecin 
de  St.  Lazare;  Ex-Chef  de  CJinique  k  L'Hopital  St. 
Louis,  and  Paul  Degrais,  Ex-Chef  de  Laboratoire  k  L'Hdpital 
St.  Louis. 
Svo,  Cloth,  53  Illustrations,  viii-j-111  Pages $1.25  net. 

WRENCH :     The  Healthy  Marriage.    A  Medical  and  Psycho- 
logical Guide  for  Wives.     By  G.  T.  Wrench,  m.d.,  b.s.  Lond., 
Past  Assistant  Master  of  the  Rotunda  Hospital,  Dublin. 
2nd  Edition,  Svo,  Cloth,  viii+300  Pages $1.50  net. 

WRIGHT:    The  Unexpurgated  Case  against  Woman  Suf- 
frage.    By  Sir  Almroth   E.   Wright,  m.d.,  f.r.s. 
Svo,  Cloth,  xii-f-188  Pages $1.00  net. 

WRIGHT:  On  Pharmaco-Theeapy  and  Pbkvbnttve  Inocu- 
lation; Applied  to  Pneumonia  in  the  African  Native,  with 
a  Discourse   on   the   Logical    Methods   Which   Ought  to   Be 


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16  HOEBEB'S  MEDICAL  MONOGBAPES 

Employed   in   the   Evaluation   of   Therapeutic   Agents.     By 

Sir  Almroth  E.  Wright,  M.D.,  F.R.s. 

8vo,  Cloth,  124  Pages $2.00  net. 

YOUNG:  The  Mentally  Defective  Child.  By  Meredith 
Young,  M.D.,  D.P.H.,  D.s.sc,  Chief  School  Medical  OflScer, 
Cheshire  Education  Committee;  Lecturer  in  School  Hygiene, 
Victoria  University  of  Manchester;  Certifying  Medical  Offi- 
cer to  Local  Authority  (Mental  Deficiency  Act),  Co.  Cheshire. 
12mo,  Cloth,  xi+140  Pages.     Illustrated $1.50  net. 

Complete  catalogue  and  descriptive  circulars  sent  on  request. 


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